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** ATTENTION' APPLICANT ** <br /> Fill in all a ro riate blanks and check al( 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: .� <br /> Size of Tanks: <br /> Treatment System <br /> Trenches s.f. <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 under�igned hereby a�plie� +o th� Gity 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: �h - �-S � ���� <br /> MPCA License No.: � $� <br /> Staff Review: �Accept ❑ Denied <br /> Rev iewe r: ��/ �LL � � <br /> Date: � � ��— � � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> Reset Form <br /> V:\(Permits)\Septic Permit Application-New Permit Fees 2009.doc <br /> 2 � 2 <br />