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J <br /> � ' 40� City of Orono FOR CITY USE ONLY <br /> P.O. Box 66 '7 <br /> �'" � 2750 Kelle Parkwa Date Received: �/ `� / Permit# G-L'l�" �'� _.�'(� <br /> ��t Y Y � <br /> � '�rR.fw'_ �. C stal Ba ,MN 55323 <br /> ��j y,r�, rY Y . <br /> ���,��$o` (952)249-4600 Amount: $ i G� ��` !_._ ';;'�'�� �� � ('>�/l <br /> CITY OF ORONO — SEPTIC SYSTEM PERMIT APPLICATION <br /> (Ail permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> ;1ob S ite / C� ;��� "�'c�§ ,,e.;ti�n �� � ;��.�x�« �, ;;� <br /> Site Address: �C��� p«= �'Un Tr�: � <br /> Owner: �'`� <��,� �� L�=���� � -Sw z��S��n Mailing Address: <br /> City: � ^��n �� Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant Information: <br /> Contractor/App.: ��^`�r �. ►-'�-��5�., Cc1 . Contact Person: �' "` ��``cl��""�"�` <br /> Address: ��2 ( ��'� `''� � �'� S�=. State License #: 2/1 <br /> Cit : ��-����"��' Zip: � S�2� Expiration Date: <br /> y <br /> Phone: ���3, � ?2 ���2�� Alternate Phone: C�(2 zo 2'� 5o j �c/� <br /> �,. ° �N gTYPES OF OCCUPANCY,'. �: ` = � �' � ����� ,� q..£. <br /> (� Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES _ ,,�. � <br /> New o�Replacement System $200.00 .,��. �-- <br /> .\ ,; <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> � � ���_, <br /> Total $ �,����� 5 '"� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />