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** ATTENTION APPLIGANT** <br /> Fill in all a ro riate blanks and check ali appropriate boxes. <br /> I will be installing the following: <br /> Tanks <br /> ❑✓ Precast Concrete � Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: 3 <br /> Size of Tanks: �,000 �,000 �,000 <br /> Treatment System <br /> Trenches s.f. <br /> X Mound 83x37 s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> Final Cover/ Top Soil <br /> 0 to be borrowed from site (show location on site plan) <br /> ✓� trucked in <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, true and correct. <br /> Signature of Applicant 09/09/09 <br /> MPCA License No.: 1888 Reset Form <br /> Staff Review: Accept ❑ Denied <br /> .... �.. <br /> Reviewer: Date: � '- � L��C� � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> V:\(Permits)\Septic Permit Application-New Permit Fees 2009.doc <br /> 2 � 2 <br />