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� City of OrOno FOR CITY USE ONLY <br /> 0� '��� P.O. Box 66 � � <br /> 2750 Kelley Parkway Date Received: Permit# <br /> � � _� a' Crystal Bay, MN 55323 <br /> �{�� <br /> �y u• � � ' Amount: � <br /> ������;��$� (952)249-4600 <br /> aexo�' <br /> CITY OF ORONO — SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> Job Sife / Owner information: �:��� � <br /> Site Address: ����(n� �C 7� �'�'���� �� � <br /> Owner: �.�:��..,.,:��; ��� Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/Applican� lnformation: ��� � �.,,, <br /> Contractor/App.:l� := '� ��-l�� �,�: � � Contact Person: ����� ��'� <br /> Address: Y� ��� S� State License #: �-`� Z� <br /> City: l�rb�o���.�� Zip: ���4-�� Expiration Date: z -�� <br /> Phone: Lc;( Z, ZZ I — I`( �t 3 Alternate Phone: (.� 1 Z Zz I - `?�S Z <br /> ,..� ,.� ��I'�PES'�F:RJCCI"JI��N�Y . ':'° '� :. � . s ��.+_�� > � � ��: <br /> �2esidential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES �� <br /> < z= <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 />