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� ' <br /> , ,��� City of Orono FOR CITY USE ONLY <br /> O p� P.o. BoX ss �-• , <br /> � 'i` Permit# ��C'/�' _ C�� .7� <br /> e�;t,�e 2750 Kelley Parkway Date Received: �; � , ,_ � <br /> a '�t���z � Crystal Bay, MN 55323 <br /> '� ��� '� Amount: � <br /> a�����o;�.$o` (952)249-4600 <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: �r. ,, �a�;�� <br /> Site Address: � � r� ����'I'���v1� f-'1 ���i+ � �D - <br /> �-- <br /> Owner: � lv�(✓� [.�-��I� �.ti-� - Mailing Address: �� �A '���� � '�`�, <br /> City: �i r��^�A/,c �' S Zip: .ss ��� <br /> Home Phone: ��� '�y 7 ' ��y�' Alternate Phone: <br /> Contractor/.Applicar�t:lnformation: <br /> _ .-� ✓— <br /> Contractor/App.: ��.�4� �'�����" � S�"'`� Contact Person: r J �'}� <br /> Address: ��� - �4 �l� /�cJ�'. State License #: �� � <br /> City: ; C�'�=� Zip: ��5.�7`� Expiration Date: � ' �v � 3 <br /> Phone: (o/ :� � �l�`f '�S( G Alternate Phone: ��y��' � ��-� <br /> , , <br /> .���. � <br /> �° TYPES=°QF��'?CCUPA�ICY ° � � �� ' � ' <br /> ��, � � � �� �, � <br /> � r . <br /> ,_,� �. �., ^�.�1.,, ^��s,�g � ,, ; _, �. �, � <br /> Residential ❑ Commercial ❑ Other <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 /> Total � r����G� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />