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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 /> �]- Prec �t� Fiberglass ❑ Plastic ❑ Other <br /> � (list manufacturer) <br /> _ � �,s�,� -- <br /> / t,qHkS <br /> Nu s: � ; ��. 5f�+ /�z� /�ibr�-i TcY..r .��i�hS,:., } <br /> Size of Tanks: f CC'C� ,,.�c<<G, <br /> Treatment System <br /> Trenches s.f. <br /> � Mound C���� s.f. �� J� � � <br /> �� <br /> Gravel less s.f. <br /> Chamber s.f. <br /> Final Cover/ Top Soil <br /> to be borrowed from site (show location on site plan) <br /> � trucked in <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 ���-Y -1 �'` -t'� Date: /� - lUr- U S <br /> MPCA License No.: �% �� <br /> ; <br /> Staff Review: �ccept ❑ Denied <br /> Reviewer: �� J� ,�� , ��� Date: � / - �f�'� � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> V:\(Permits)\Septic Permit Application-New Permit Fees 2009.doc <br /> 2 / 2 <br />