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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 /> � ^ <br /> Number of Tanks: 3 ���-Se. L5-�Lvt '{�-v�L�S ��J <br /> �^� -f-l.��,k a-�- a ►'�-e. �.v �► � 3 c� oq�c o r� �wt p -�y1k. r�� <br /> Size of Tanks: J p <br /> � 3c�v l c�c� 13c�v <br /> Treatment System <br /> Trenches s.f. <br /> �_ Mound � 3 d 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 /> Signature of Applicant Date: <br /> MPCA License No.: <br /> Staff Review: ccept ❑ Denied <br /> Reviewer: ~ Date: � J��' �� <br /> Reason for enial: <br /> Comments (to be printed on inspection card): <br /> ���� �1�� �o f� ����i� G���� ��1� 1,��� �� <br /> v - <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />