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**ATfENTION APPLICANT** <br /> Fill in all a ro riate bianks and check all a ro riate boxes. <br /> I will be installing the following: <br /> Tanks <br /> �] Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> Qist manufacturer) <br /> �� <br /> Number of Tanks: _�J <br /> Size of Tanks: � <br /> Treatment System <br /> Trenches s.f. <br /> �.� - 1 tr` `•..�,;� <br /> � �� C%(.' S.f. <br /> ��.��k�� <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 MinnesqCa and certifies that all statements made on this <br /> application are complete, true and cq��i�'ef: - <br /> ' '�,' r <br /> Signature of Applicant ������--��L`--'�--�-�-- Date: �7 -� � �-� <br /> --___ _ <br /> .F- <br /> �l;i ,\ <br /> MPCA License No.: ��;' `-_ <br /> Staff Review: �, Accept ❑ Denied <br /> Reviewer: � Date: Z � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> 2 / 2 <br />