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.� � <br /> ¢0� City of Orono FOR CITY USE ONLY <br /> P.O.Box 66 ,b <br /> ��;;,;, � 2750 Keiley Parkway Date Received: 7 / Permit# ��t"� � � <br /> ���'���jr Crystal Bay, MN 55323 <br /> � _�;� �' <br /> '����,� (952)249-4600 Amount: $ D0. / <br /> $ <br /> CITY OF ORONO — SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building O�cial) <br /> Job Site/ t�wner�.fnformation: <br /> , / . <br /> Site Address: � � ��� � a�L� r`Oi�� <br /> Owner: � c� t� � �c t�-����i` Mailing Address: J��l�+�� <br /> City: �_ �y Z,c4( � Zip: .�s 3°j� <br /> Home Phone: �I�a ' aS� — �o��a Alternate Phone: <br /> Contractor/Applicant Informati�n:; t �� ,rt;�� <br /> � <br /> � � <br /> Contractor/App.: �E41 ti^�� c �— �!U� Contact Person: �U�i'� ��'`'�� <br /> �1 i � <br /> Address: oc 3 oto� � �� '�' �r State License #: �S <br /> City: ��S Zip: �5��� Expiration Date: �uL <br /> Phone: �lo� ` �o��� 73�1� Alternate Phone: ��a`q�`f' D�� <br /> TYPES C'�F IJCCUPANCY <br /> � Residential ❑ Commercial ❑ Other <br /> � PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 �4�0- �G <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 -�rfr6• • 5v <br /> Total $ . `� �� .S`� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />