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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: �- I�f'=' `�>�'�;'� �C' (- I°�'�' P``'`�� <br /> Size of Tanks: ��� �Q�7�> ' ' � ; <br /> Tre�tment S�m _ <br /> `�' F, � -� 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 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 /> . � , <br /> Signature of Applicant �� ��x G �!���= Date: %/� / "' �c <br /> �— <br /> MPCA License No.: �� <br /> Staff Review: ,� Accept ❑ Denied <br /> Reviewer: ,��,,� ,�g� __ __ Date: � (� � '�D <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 � 2 <br />