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f � +-' <br /> I ** ATTENTION APPLICANT** <br /> � Fill in all appropriate blanks and check all appropriate boxes. _ ___� <br /> I will be installing the following: <br /> Ta ks <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: -� <br /> Size of Tanks: /S�C,� /_`��,>�� �5 G'�� <br /> Treatment System <br /> Trenches s.f. <br /> � '? ��'�-� <br /> _� Mound ���� �( �/ 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, tr and correct. <br /> Signature of Applicant Date: �� ���� <br /> � <br /> � <br /> MPCA License No.: � ��� <br /> Staff Review: ;� Accept � , ❑ Denied <br /> , <br /> Reviewer: �� �-��--s �'���� Date: �� J � ' � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> Reset Form <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 � 2 <br />