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`���~' City of Ofono FOR CITY USE ONLY <br /> P.O.Box 66 <br /> � � ��� 2750 Kelley Parkway Date Received: Permit# <br /> ,' � Crystal Bay,MN 55323 <br /> i (952)249-4600 Amount: $ <br /> ���%� ti% <br /> \ `��SHpQ`�v <br /> \ <br /> CITY OF ORONO —SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> Job Site/ Owner Information: <br /> Site Address: �� ��.� ���l`�1����A- � /�l L L. ,��'�9<-'� <br /> Owner: /�/1��� r�-'"l�5 L_IV l�L�l�'L � Mailing Address: �'S <br /> � �`- /��1L��? !<����� <br /> �� ._ _ <br /> City: G°1�i C� .t-1 l��"- _ Zip: `��� J C� <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant Information: <br /> Contractor/App.: 1���k"iti� c k�'�-�Vv'�7�/��L Contact Person: '=>i L. V i� �;�t,�'��/� <br /> Address: �`� �t.,� i��t i�ll��{ /�L'� �/ State License #: � ���'� <br /> City: I�ll�y�iC. Zip: `> � ��`U Expiration Date: /�-1l�1��'�� j�'`j`� <br /> Phone: ��S z� % �5 � -��1� Alternate Phone: �`��� ��S -`��'-.� <br /> TYPES OF OCCUPANCY <br /> , <br /> [� Residential ❑ Commercial ❑ Other <br /> i <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> � c� <br /> Total � � �� � <br /> W:\(Applications,License or Permit Applications)\Permits\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />