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� <br /> ' � �p��� City of Orono F R CITY USE ONLY <br /> \ P.O. Box 66 <br /> ��s � � 2750 Kelley Parkway Date Received:���l��Permit# � "d� � � <br /> a �{!;•i::. F� Crystal Bay, MN 55323 <br /> m �Y!U'�;�� , � Amount: $ J�.�� <br /> ����o�$o� (952)249-4600 �, � <br /> � �� l <br /> CITY OF ORONO - SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> Job 5ite / Owner In#ormation.: ,����,�;;; <br /> , \ <br /> Site Address: ` fi 2- L �--���'V� �1 �-�(Z-I V' � <br /> � i � ` <br /> Owner. Zc�,c.� � �j ✓��-�c � Mailing Address: �Z� ��`''�`� (" � <br /> City: v �� ; Zip: S'�5'� � S`I <br /> Home Phone: Alternate Phone: <br /> Contractor 7.��PPlicant lnfqrr����n ��� ��: <br /> Contractor/App.: �t �y�� � S�� 7 Contact Person: � �'•� -� <br /> Address: �� � �- �5� ��' State License #: L (v � � <br /> City: �?����"�� Zip: �5�� � Expiration Date: � �` Z�' z— <br /> Phone: 7� 3 � 7�i / 7(�'Z� Alternate Phone: �/Z � �5 `7 S S� <br /> T <br /> ` 7Y°PES-�JF�Q�"�CUPANC'1( " ���`; ��,��� ���:g������,_ ��� ��a <br /> �Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 'Z-v�-� <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ �Z�� <br /> W:1(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />