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, � /1 <br /> - City of Orono q, � l� `� FOR CITY USE ONLY � <br /> ��' �10/�/'�� P.o. soX ss I , ,. ;� , �;���' i,;' ^ <br /> Q `. 2750 Kelley Parkway Date Received: "� �!( � , Permit# ^^��_ � � <br /> , Crystal Bay,MN 55323 ,C-v� <br /> � � � ! (952)249-4600 Amount: $a�✓ <br /> : ' � ' <br /> f � <br /> \ <. -�'� � <br /> ��- i�E,tt����:i� <br /> �lTY �OF L��fll��fl = S�PTlC SYSTEP�! QE�:��JlT �PPLlC.�TlON <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> Job Site / Qv�ner infarma�ie�n: <br /> Site Address: l �C; �-�- �c.�.y�� L����,_.�., j��. __ <br /> �"v h u }-�z:.u-�c,,_ <br /> Owner: -���u�� �-�-���-��� , t- Mailing Address: '�`, �'"'``�'`�� -- <br /> c ��s'>� � <br /> City: ���1� �-��I;� Zip: �53..�L- <br /> Home Phone: Alternate Phone: �%� ":�:����� 1�% ��'S� <br /> Contractor/Applicant Information: <br /> Contractor/App.: �\�vo �� �J��'�. �n�u�<<���� Contact Person: �c; ��: c� �- �_� <br /> Address: �,l��"„`;� �l��z >�'`' State License #: �;;Z l �L; �� � i�J� <br /> ���_ <br /> � <br /> ^ /It��L 1.� �`=- 1 `t- <br /> City: ;,)����_�:� Zip: �..�-��._5� Expiration Date: l� �3i ��cu 1� <br /> Phone: �.3v�v� .��.5— 3�'i,5 Alternate Phone: <br /> TYPES OF OCCUPANCY <br /> [�Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES <br /> �7 <br /> New Replacement System $200.00 � � <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> �� <br /> Total $ ���- � <br /> W:\(Applications,License or Permit Applications)\Permits\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />