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� <br /> � � <br /> p City of Orono � FOR CI USE ONLY <br /> ��'g' �� P.o. Box ss �" ti1l 1� . (� �.j� <br /> � �a;,,; 2 7 5 0 K e l l e y P a r k w a y �.Y� D a t e R e c e i v e d. �� P e r m i t����� / � <br /> ,�... r� <br /> �� ��j�i�.,��,. � C rystal Ba y, MN 55323 p-o <br /> � ^(�� �y�o (952)249-4600 Amount: $�05 _ �� ��i ��0265 <br /> \���a� <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: �� (J U �t���, f�r�v►� � � LL �,,� <br /> Owner: 5(0.�� woo� �, �, L, Mailing Address: (�'� ��' �(9� ����-� <br /> Clty. `"����A%/L' Any7�tS ZIp. ����Y' <br /> Home Phone: ��� - ��17 - �� `j�� Alternate Phone: <br /> -Contractor/Applicant lnformation: ���„�� <br /> i"� --- �— --� <br /> Contractor/App.: ( � l ti�o,�) � -� �,tiS Contact Person: � D �. �-(!v v�� <br /> Address: a3�oo ( C�`� �s ��-lv�' State License #: � �? <br /> City: �.c��nG��.s Zip: ���> 7� Expiration Date: �L�-� � ��- <br /> Phone: 7�.� - �-��� - 7���j'�3 Alternate Phone: (�I-� � `f�`f��5��' <br /> TYPES OF OCCUPANCY �.:= � 4.,, <br /> �Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES , t��� <br /> New or Replacement System $200.00 ,�C`?C) > � � <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> �,c� <br /> Total $ �1 G � � <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />