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� � <br /> ** 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 /> Tar}�ks <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: c� � <br /> Size of Tanks: l5 D� / Sf�� ; <br /> �� l � <br /> Treatment System <br /> Trenches s.f. (�j� � �� <br /> � Mound � s.f. ��� ��`� x� �`� <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 __ _ �)l�, Date: � � <br /> MPCA License No.: � I I f <br /> Staff Review: �'�Accept ❑ Denied <br /> Reviewer: /� ,�f _ �,1���� �� � =�� Date: �I'� � ' � l <br /> —�– �a�� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)1Septic Permit Application-Updated Surcharge 07-14-11.doc <br /> 2 � 2 <br />