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(Updated 1/5/04) <br /> CITYAF �,:.RONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL 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. Permit cards will be sent by return mail the same day <br /> the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Work must not begin unless the pernut 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 utility stub as-built locations. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP ANl'MAIN without express approval of the Public Works Department. Issuance of a pemut does not grant 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 required. <br /> JOB SITE ADDRESS: �%�' �`���-''`�'-��� ��'�7 ✓'�/,I, <br /> Occupancy Type: �_Residential Commercial <br /> Owner's Name: �'.��� ;, f�%S Phone 1\umber: �s� ' ��/` d�7� <br /> Mailing Address: /'7�5� ��; � N s ,,Ur R�l City: /,��Nn Zip: S s�-._3i/ <br /> Contractor's Name: �l� //;i��T✓ �5��'�����Phone \umber: 1 s��-- y73- i�y7 <br /> Mailing Address: ,�C��,� �. 2�. l�/ City: d'�'i�n%,��k.� Zip: SS3i'l <br /> PERIVIIT TYPE �Connections ❑Repairs ❑Disconnect (Check One) <br /> SAC Charge (2003 rate $1,350.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer permit applications unless prepaid. <br /> (If not prepaid, a sewer connection will not be issued) <br /> Municipal Sewer Connection/Disconnect/Repair (S35.00 per stub) $ <br /> pipe size inches; material Schd 40 air tested; cast iron <br /> Municipal Water Connection/Disconnect/Repair(S35.00 per stub) $ <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 `Vater 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 pernut requested. <br /> 3. Postage & Handlin� (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ <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 with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements <br /> made on this application are complete, true and correct <br /> ,� . <br /> Signature of Applicant: �__ Date: o d <br />