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F (Updated 6/2/03) <br /> CITY OF ORONO y� �`1���APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) r� � SEWER/WATER& SAC <br /> Crystal Ba�'j�,MN 55323 �}_ ��D � <br /> . �� <br /> GE�IERAL INFORMATION <br /> 1. You may apply for utility pernuts by mail or in person at the City offices. <br /> 2. Mailed in applications are subject to the postage and handling fee shown below. Pernut cards will be sent by return mail the same day <br /> the application is received. <br /> 3. Permits are not valid u�til you receive a permit card. <br /> 4. Work must not begin unless the permit card is available on the job site. <br /> 5. Utility connection pernuts may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(952-249-4600)for urility stub as-built locations. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP ANY MAIN without express approval of the Public Works Department. Issuance of a permit does not gzant this approval. <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work must be inspected before it is covered. Call(952)249-4600,24 hour notice r uired. <br /> . � � �,/ ' <br /> JOB SITE ADDRESS: - �S^ � �� �� /� r � � � <br /> Occupancy Type• Residential ommercial // <br /> O�i•ner's Name: :����� �_/��U�– Phone Number: ��� - �C%/� s�Y �� <br /> iviailing Address: -------- �� City: Zip: .-- <br /> Contractor s Name: ��.- ' E'i��-��%• Phone Number: <br /> Mailing Address: � City: Zip: �V� <br /> PERMIT TYPE Connections ❑Repairs ❑Disconnect (Check One) � � <br /> �� <br /> SAC Charge (2003 rate $1,275.00) $ (Set Rate) <br /> 5ac Charge must accompany all sewer permit applications unless prepaid. <br /> (If not prepaid, a sewer connection will not be issued) <br /> � O <br /> Municipal Sewer o nection/Disconnec�t/R�e ir ($35.00 per stub) $ <br /> S� G <br /> pipe size inches; material "( Schd 40 air tested; cast iron <br /> Nlunicipal Water Connection/Disconnec e 'r($35.00 per stub) $ �S/ �J <br /> pipe size�inches; material copper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> Water meters must be set and sealed by Orono Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQUIRED minimum setbacks from drain field and septic tanks = 75' <br /> REQUIRED setback from sewer line=20' <br /> PERIVIIT FEE CALCULATION <br /> l. Subtotal of above permit requested $ � �� <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per pernut must be <br /> included for each well,sewer and water connection pemut requested. � <br /> 3. Postage & Handlin� (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ ��- c'�J <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do all work in strict <br /> accordance w�ith the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements <br /> made on this application are cQ�pl rue and correct,_____ __ <br /> -- -----� /�^� <br /> Si�ature of�lic _ - —� Date: 2– �� <br /> � <br />