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CIT'Y OF�ORONO APPLICATION FOR UTILITY PERMITS �pdated 5/3/02) <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL INFORMATION <br /> 1. You may apply for utility pemuts by mail or in person at the City offices. <br /> 2. Mailed in applications are subject to the postage and handling fee shown below. Pernut cards will be sent by return mail the same day <br /> the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> -�. Work must not begin unless the pernut card is available on the job site. <br /> �. Utility connection pernuts may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(952-249-4600)for utility stub as-built locations. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP AN1'MAIN without express approval of the Public Works Department. Issuance of a pernut does not grant this approval. <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work must be inspected before it is covered. Call(952)249-4600,24 hour notice required. <br /> / ,�` .�'�,..�. <br /> JOB SITE ADDRESS: �J �'� '�� L,,;� ""`' �.. '.,�''��'�4� �.�r W <br /> Occupancy Type:/� Residential Commercial <br /> Owner's Name: c�-��� �,,.-+7 p..� Phone Number: <br /> Nlailing Address: City: Zip: <br /> Contractor's Name: A�a�..`f,�,�. �c�fa,� ���f�{ �. Phone Number: �y i� <br /> 1�Iailing Address: City: Zip: <br /> /�Z�� s �. ,, <br /> PER�iVIIT TYPE �Connections ❑Repairs ❑Disconnect (Check One) <br /> SAC Charge (2002 rate $1,200.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer permit applications unless prepaid. <br /> (If not prepaid, a sewer connection will not be issued) <br /> , � �� <br /> 1�Iunicipal Sewer Connection/Disconnect/Repair($35.00 per stub) $ ��� <br /> pipe size�inches; material Schd 40 air tested; cast iron <br /> l�Iunicipal Water Connection/Disconnect/Repair($35.00 per stub) $ <br /> pipe size inches; material copper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> Water meters must be set and sealed by Orono Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQUIRED minimum setbacks from drain field and septic tanks = 7S <br /> REQUIRED setback from sewer line=20' <br /> PERl`ZIT FEE CALCULATION <br /> 1. Subtotal of above permit requested $ �� � <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per permit must be <br /> included for each well,sewer and water connection permit requested. <br /> 3. Postage &Handlin� (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ „3�"x_y� <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do all work in strict <br /> accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements <br /> made on this application are cor�plete, true and orrect. <br /> ` � .�° � � <br /> Si�nature of Applicant: -�--'" F'���"Y`�-.� Date: �'� � ;i' �"" <br />