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** ATTENTION APPLICANT ** ' � - � <br /> Fill in ail appropriate blanks and check ail appropriate boxes. <br /> I will be installing the following: <br /> Tanks _� <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other �f��w• <br /> (list manufacturer) <br /> Number of Tanks: 2 . <br /> Size of Tanks: ����4�:.( �c� ��. �`'�'`��"�<� <br /> Treatment System <br /> Trenches s.f. <br /> � Mound /�,�4� ���k��� s.f. �3 ����. <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 Applican���?��� Date: IO -/ 2 - Il <br /> MPCA License No.: ���7 <br /> Staff Review: �Accept ❑ Denied <br /> Reviewer: l�t�Cl" Date: �d � ��'� � <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 />