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� <br />� g�� City of Orono f R CI USE ONLY <br /> P.O. Box 66 � ��.,�'l D / <br /> ��ht,e; � 2750 Kelley Parkway Date Received�,' �� � Permit#v K-��'�—� ` <br /> a �'�t fl•f{ Crystal Bay,MN 55323 �-- h <br /> 6�. ��,� f �," ����V <br /> ���}'i�..$o` (952)249-4600 Amount: $ <br /> �ae <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 Inf.ormafiia� `` ° ' �` ` Y <br /> Site Address: ��3 �� � �4'�- ��� ��� <br /> Owner: d�"1� !" �� pG Lp k� Mailing Address: <br /> City: D �� "' �' Zip: <br /> Home Phone: Alternate Phone: ��r J � ��5 3�3 I <br /> C�� � g� 7 _��.2� <br /> Contractor/ Applicant Infor�ti�a�'R ' <br /> � ,, <br /> Contractor/App.: f=�"`C�`�• t��`f S�� � �� _ Contact Person: �'�. �''�-�'��`"��^'� <br /> Add ress: 5 j 2� D�� �e. �U� State License #: 2 � � <br /> City: /-����r� Zip: '�5 3 i`�' Expiration Date: <br /> Phone: ��.�J % �`L- 2-`t`Z° Alternate Phone: C��Z z�2�� �c�9 <br /> ��`; ;� ���" '°��.,:z�� �```� ' T1�,.�ES OF OCCUPANCY �� �,.� � �n� ����� <br /> (�( Residential ❑ Commercial ❑ Other <br /> ..��.�;: ��� �:x � ` �.,�.�.� �� `:�:�� PERMIT TYPE AND FEES �����.''� , �:, ,�.., <br /> New or Replacement Syst� $200.00 ��a� �� <br /> �_ <br /> _____- <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ L�� ���� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />