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� <br /> , , � <br /> ** ATTENTIO�J APPLICANT ** <br /> Fill in all a ro riate blanks and check all a ro riate boxes. <br /> I will be installing the following: <br /> Tanks <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: � <br /> Size of Tanks: 1�'�� 1��� � I��a <br /> Treatment System <br /> Trenches s.f. <br /> _,�__ Mound �{c5�C�3 s.f. 10 1< 5 a �'� � l< ,Q�� <br /> Gravel less s.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <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 Applican9� ' �- Date: � �� �—�� <br /> MPCA License No.: 2��7. <br /> Staff Review: Accept ❑ Denied <br /> Reviewer: �����'(�-✓ Date: �'��� �L <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />