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. <br /> ' ** ATTENTION APPLICANT ** <br /> Fill in all a ro` riate blanks and check all a ro riate boxes. " <br /> I will be installing the following: <br /> Tanks <br /> ❑ Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <br /> Size of Tanks: <br /> Treatment System <br /> Trenches s.f. <br /> � n I� r� �� �`� <br /> Mound ��� s.f. l�z��c�---e . e�C � 5'�-`^�, �,�- <br /> Gravel less s.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <br /> The undersigned hereby applies to the City of Orono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete, true and correct. <br /> Signature of Appfican��`�'��-�'�� Date: / � � y - l � <br /> MPCA License No.: � ) ( <br /> Staff Review: � Accept ❑ Denied <br /> , <br /> Reviewer: � ' ` <br /> � ..i( �=�" .�c ��'� Date: / � " � S� " � / <br /> � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />