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;,¢� • City�f Orono FOR ci USE ONLY <br /> O,r. O P.o. Box ss 1j � ����j/ <br /> = 2750 Kelley Parkway Date Received� � � Permit# <br /> � �x�`w. +� Crystal Bay,MN 55323 <br /> �;'���;��o' (952)249-4600 Amount: ����-�� <br /> ���oa <br /> �� � <br /> �/���3�' <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�Jnformation; ur `' " <br /> Site Address: <br /> ` c C �� �o �/��-► ��C 11�`. <br /> Owner: �c���;z � �"���4-� ��� ^z Mailing Address: <br /> City: ��cfl� � . Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant lnformation: �q ��s;', <br /> ��,•` ^� <br /> Contractor/App.: �-1''`��� - n���2�5�'� C� Contact Person: J'�"` ��"'e9y�'`"^" <br /> Address: .���2� ��2�� �`"'� .S� - State License #: �� �/ <br /> � <br /> City: pr��-tio Zip: J�3Z� Expiration Date: �"13--2v�?� <br /> Phone: (���/ �7� L " 2-�`�-� Alternate Phone: C�l 2 ��-�5 p`1 <br /> ' �� ��$. ��,"�'`�'���R'� �'�T��?�E��C) ��"����LlPANCY ����� �,.�t�� , � ������ �,����� ',..�...:� <br /> �. <br /> � Residential ❑ Commercial ❑ Other <br /> ��: �� �����`� ;.���.�.:��§_�,� PE:RM ,�P.E=AND`FEES `� � �, ��� <br /> New or Replacement System $200.00 _�L FX� — <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ �0 5---- <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />