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(LTpdated 6/2/03) <br /> CITY OF ORONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL INFCI�MATION <br /> 1. You may apply for utility pernuts by mail or in person at the City offices. <br /> 2. Mail'ed in applicarions are subject to the postage and handling fee shown below. Permit 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 /> 4. Work must not begin unless the pernut card is available on the job site. <br /> 5. 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 ANY MAIN without express approval of the Public Works Department. Issuance of a pernvt 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 /> JOB SITE ADDRESS: I I 6 �`� ���'�C� �� <br /> Occupancy Type: Residential Commercial <br /> Owner's Name: �� �� '�r c Phone Number: <br /> Mailing Address: City: Zip: <br /> Contractor's Name: C-� G '�ti ^ f'_�,, �-�•-"�-c.�hone Number: � S.Z �-(� �� Z,3 � <br /> Mailing Address:S� �`�, � � c�:-�e.. �,n ,-.� � _ City:������ Zip:��S �, b-F <br /> PERl`1IT TYPE onnections ❑Re airs ❑Disconnect (Check One) <br /> P <br /> SAC Charge (2003 rate $1,275.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer pertnit applications unless prepaid. <br /> (If not prepaid, a sewer connection will not be issued) <br /> Municipal Sewer�onnection/Disconne t/Repair ($35.00 per stub) $ <br /> pipe size inches; material�chd 40 air tested; cast iron <br /> Municipal 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 /> REQUIlZED minimum setbacks from drain field and septic tanks = 75' <br /> REQUIRED setback from sewer line= 20' <br /> PERMIT FEE CALCULATION <br /> 1. Subtotal of above permit requested $ <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Buildiiig Code Division Surcharge of$.50 per pernut must be <br /> included for each well,sewer and water connection pemut requested. <br /> 3. Postage & Handlin� (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ <br /> The undersigned hereby appli to the City of Orono for issuance of a Utility Permit, agrees to do all woxk a� �trict <br /> accordance with the ordinanc of the City and the regulations of the State of Minnesota, and certifies that all st�g�rxa�nts <br /> made on this application are omplete, true correct. <br /> � � <br /> Signature of Applican . Date: �� �� ��3 <br />