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'i <br /> ** ATTENTION APPLICANT '�* <br /> Fili in all a ro riate blanks and check all a ro riate boxes. <br /> I will be installing the following: <br /> Tank j��d�� <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other �� <br /> (list manufacturer) <br /> Number of Tanks: � <br /> Size of Tanks: 1�'C� �``��� <br /> %' -��� l i��c�' <br /> Treatment System <br /> Trenches s.f. <br /> �.�_ (��o� Mound 1 soo� s.f. I� 'S L. . ,.��1.�1 � 'F��zz -}- <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 corr ct. <br /> �— <br /> Signature of Applicant ���� Date: S `� l 3 <br /> MPCA License No.: � �S <br /> Staff Review: �Accept ❑ Denied <br /> Reviewer: �-`�� � ��"C (.'�• ��.,�� � Date: � ' ��� � 1 � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> �-/� C�� � � � `_7 �'�'��1-. �' �j 4-� n iG � ���� c r� t-y '�� I,a �C�� <br /> Cr�} i (d�►.� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />