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�► <br /> � , <br /> ** ATTENTION APPLICANT ** � <br /> Fill in all appropriate blanks and check all appropriate boxes � <br /> J <br /> I will be installing the following: <br /> T nks <br /> �Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> � � (list manufacturer) <br /> Number of Tanks: .3 <br /> Size of Tanks: � 3��' j � c�v ` ��U <br /> Treatment System <br /> Trenches s.f. <br /> ✓ Mound Cv� C� 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: ���Z -�� <br /> MPCA License No.: �� L(� �-{(� <br /> Staff Review: '�Accept ❑ Denied <br /> Reviewer: �t � ( ��_,�l� S Date: �'��'� �ri <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> L�� �i � � C ,�SS� 2S G � 1 UPfT t"� �;gGe,T <br /> l�� S � �� 5 � �5 . -�.. <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 / 2 <br />