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� **ATTENTION APPLICANT** <br /> Fill in all a ro riate blanks and check all a ro riate boxes. <br /> I will be installing the following: <br /> Tanks <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: ���U��i�IL� .� -n,L�l�� � ���T�15�n'� ������� <br /> Size of Tanks: �«��� �GU CC iL.'ll �? <br /> Treatment System <br /> Trenches s.f. <br /> � ���-�- 1�tvL. t< B�C� <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 comple tr e and correct. <br /> Signature of Ap ' Date: ��/L�/Z <br /> MPCA License No.: /��5� <br /> Staff Review: �ccept „ � �enie <br /> i <br /> Reviewer: Date: �- � � �- f`� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> Reset Form W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 /2 <br />