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i <br /> " City of Orono FOR CITY USE ONLY <br /> Q4��� P.O. Box 66 �bll9 /Y D/�j -�/ .S'r✓' <br /> �$t 2750 Kelley Parkway Date Received: Permit# <br /> a� 1�r�f`:. F) Crystal Bay MN 55323 , ��- � <br /> ��� �'wy�}�o` (952)249-4600 Amount: $ <br /> �"��'oe�'� <br /> �� I���I/2 ,� <br /> � <br /> CITY OF ORONO - SEPTIC SYSTEM PERMIT APPLICATIOf�� �j� <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) �� <br /> Job Site / Ouvner Information�`�` � n°�j���� ,��^.. <br /> Site Address: ���o ��f�/��'I �hr' <br /> Owner: �, (ir� /`3/GtU-C'�/ Mailing Address: ���i <br /> City: Zip: <br /> Home Phone: � Z '- 7' , �"� � Alternate Phone: <br /> Contractor'/Applicant Information: " ��.s��.' <br /> - / � ��. / <br /> Contractor/A ' ' �" � r ���� �/� G�'� ontact Person: FII� L��'Y's�1�''��L . <br /> N P�� r��1�5 �r � �r � <br /> ��� <br /> Address �C/.SC� G�c'S� `��`� e�� State License #: �3SC� <br /> City: ��'�t�0�� Zip: � Expiration Date: ZAl3 <br /> Phone: fS Z ��/S� �`�8(3�/ Alternate Phone: ���5�� '�5�9Z-- <br /> ('oI�Z- S3Z - ly°I Z <br /> �:�q��s ri�,nl� � � E � "�' S �.�rc.'�}� z «"�� 'w � ^"�' <br /> � a _� , �:�,,� :::�. �. .. ,� ,. ��'YPES O� OCCUP�N����(� , ,,��«���, ��,,,, � .. .� �F �� ,�, <br /> � � ` ' <br /> , �' . x � .� �� t�. ,.:��� <br /> �Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />