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.� <br /> , � <br /> ��� City of Orono FOR CITY USE ONLY <br /> r ` O., 0 P.O.Box 66 <br /> �;�,, 2750 Keiley Parkway Date Received� Permit#�U/D D(, � <br /> ��i n <br /> �, � Crystal Bay, MN 55323 <br /> ����o (952)249-4600 Amount: $ �� v� <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 /> �, <br /> Job S�ite J Qat►rner�l��nfiorrnat�o °����'� � ' ����`�������� <br /> _- ;� S� � • <br /> Site Address: � �v � � � � �� l� <br /> ev�yc�.f <br /> r'C-Q V 1 Y� a u Y.2✓ i-- <br /> Owner: � � �3� SG���`^p� W�L.��w,a � Mailing Address: Z� �� �� �"`� <br /> City: C� l.'��� Zip: 5 S'��� l <br /> ��"� � i2 5.�5_ C��Sy �, <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant lnformation: <br /> Contractor/App.: ��, � �-f- ���-5 Contact Person: � ;, <br /> Address: �2� � �Z �'''� � �` s�� State License #: L—� � U <br /> City: /�u h�{�,� Zip: S� ��� Expiration Date: j � � �� <br /> Phone: '? � � � ��5 � � �� L Alternate Phone: ��� � ��5 - � S S� <br /> =�`'� �� �� � .���, �,� "�� `;`�`�� TYPES_UF OCCU�PANCY �i <br /> �� - � � <br /> Residential ❑ Commercial ❑ Other <br /> � � �._ �'�'� PERMIT TYPE��AND FEES ���� �� ' <br /> i � �'�"� ,,;r�s " ��r_z' a.� r�m <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 /> �U <br /> Total $ �Z� � <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />