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, <br /> �OA' City of Orono FOR CITY USE ONLY <br /> �y P.o.aox ss <br /> � 2750 Kelley Parkway Date Received: Permit# <br /> Crystal Bay,MN 55323 <br /> (952)249-4600 Amount: $ <br /> ti� � <br /> G <br /> `qkfSH�Q'E <br /> CITY OF ORONO -SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building O�cial) <br /> Job Site / Owner Information: <br /> , <br /> j <br /> Site Address: �� ���C� '��' ; (!t, i" i 4�� <br /> Owner: ��' C� "►���-i��� Mailing Address � ����'-�`l V� �.U'a� <br /> City: ���''�/� � Zip: ���� <br /> Home Phone: Alternate Phone: l�� ' ` � 'l" ' �a N <br /> Contractor/Applicant Information: <br /> � ��� <br /> Contractor/App.: ��`"��`�,��L� ��� �� �ontact Person: Cl,t�v�,��'J'�✓�� <br /> / '� ' � / �� <br /> Address: � � ����� W�'�t��L� l.V I State License #: I�Vt�C1�9- U���- <br /> City: � � �✓ Zip: � �S � "� Expiration Date: ��� �-���`t" <br /> Phone: �� � � `�I'�0 � 0 � �� Alternate Phone: � �' �`� ��r / � <br /> r �) <br /> TYPES OF OCCUPANCY � �'�w� <br /> Residential ❑ Commercial ❑ Other <br /> � ���; ��. �e• �-'�� '� ��� PERMIT TYPE AND FEES� � � ' � �� � � � �� � <br /> New or Replacement System $200.00 �$ �VL%� �-(_i <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ ,�l�Sr � <br /> W:\(Applications,License or Permit Applications)\Permits\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />