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** ATTENTION APPLICANT ** <br /> , Fill in ail appropriate blanks and check all ap�ropriate boxes. ' <br /> I will be installing the following: <br /> Tan <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> Qist manufacturer) <br /> Number of Tanks: � <br /> Size of Tanks: � � � Z' f CC=�=' /oc� v1.� �� � ^�•� <br /> Treatment System <br /> Trenches s.f. <br /> � <br /> Mound � -� �% s.f. <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 correct. <br /> Signature of Applicant Date: <br /> MPCA License No.: <br /> Staff Review: �--Accept , ❑ Denied <br /> Reviewer: �� Date: � —,� 3'- I �� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />