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` City of Orono FOR CITY USE ONLY <br /> � 4�a�'�• P.o.aoX ss Q, � � <br /> �p�t, � 2750 Kelley Parkway Date Received: `� � �Permit# abl a ' D f���,� <br /> � ��°'* �� Crystal Bay,MN 55323 ��{{ ,�) !},� <br /> ��t%��;� r,`�� (952)249-4600 �-(�I^ �I' Amount: $ ��• �(/ ,�'J <br /> \.t,qnto•;/ U��1 I <br /> - ... \aV � <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 Site/Owner Information: <br /> Site Address: ; �1 LJ f"U � :� i(Lt-i�� <br /> �- <br /> Owner: __�u I'r� 1�-1(�tL- �rL%I�t T�%�\; Mailing Address: /'�IZS ��X ST�L.�-�1 <br /> city: �,ul�U���T'W- , ILtirU _ z�p: 5 5�3�r� <br /> Home Phone: Alternate Phone: ��Z �,�(� .- � J I"� <br /> Contractor/Applicant Information: <br /> Contractor/App.: �(,�,�L�`, �..�('�-�� ��17 i� Gi Contact Person: �T�Ut_.= ����-i�:j <br /> ��, � <br /> Address: �`-�7U �'L�L4iLf 1`L./ l�i�.� Zl State License #: �1u�� <br /> City: �'1�l =��_ Zip: j>jL�U Expiration Date: _���Ul��-- <br /> Phone: ����� C1 S 5 �� �l Z Alternate Phone: ��i��lG� �%r�� -'���G� <br /> TYPES OF OCCUPANCY <br /> � Residential ❑ Commercial ❑ Other <br /> �-�r <br /> PERMIT TYPE AND FEES <br /> �,c <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 � ���'� u`� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 /2 <br />