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** ATTENTION APPLICANT ** <br /> Fill in all appropriate blanks and check all appropriate boxes. � <br /> I will be installing the following: <br /> Tank <br /> �recast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: f� � <br /> Size of Tanks: � /°p� /�c� U �C�o(J <br /> Treatment System <br /> Trenches s.f. <br /> � Mound .3 �Ci s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> Final Cover/ Top Soil <br /> 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 /> - ---� <br /> ,- , <br /> Signature of Applicant � ,�_ Date: �1 - /� — b GJ <br /> MPCA License No.: C� �f � <br /> Staff Review: ;�Accept ❑ Denied <br /> Reviewer: �� ��(�. �� Date: ' <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 />