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>� <br /> , '� � City of Orono � R CI USE ONLY �� � �� <br /> � P.O.Box 66 i <br /> � 2750 Kelley Parkway D a t e R e c e i v e d. � �� p e r m i t# �r <br /> Crystal Bay,MN 55323 /") <br /> (952)249-4600 Amount: $�r���(J <br /> a � <br /> 6 ti <br /> F L <br /> t�'F6S H��� <br /> CITY OF ORONO - SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building O�cial) <br /> � �I?v ' �� <br /> .'^S%-. �3'.�`�. MiM . <br /> ;}It. N3, .�5`;`� <br /> Site Address:��b � � 4.c o�s /�'ti�� Ro �, � <br /> Owner: �'Cv�,T ca�.„/ �scl�r�,; � � Mailing Address: <br /> City: !�h �.�r� iYr�V Zip: s,j ,��`� <br /> Home Phone: �`a- ,�c4�- �y$�_ Alternate Phone: <br /> _ � , �. �.. . . � <br /> �_.� , <br /> . <br /> � � a� <br /> Contractor/App.�a,�TYS EX� ��Ti.�q Contact Person: �� z � <br /> Address: �� SS Rv7-Z- L�, bre 2o�,r� State License #: �6 � <br /> City: �i9Y�- Zip: Ss36�� Expiration Date: d y-DS- 2OI y <br /> Phone: �Sa' �s7 � �54� � Alternate Phone: �!�- �76c�' ^ �S8/ <br /> . , <br /> ; <br /> � <br /> . , � .. �� .� rt� , <br /> � Residential ❑ Commercial ❑ Other <br /> � � � ; �� � : � . v �� � ���, �� ,.� � ����� _ , , <br /> New or Replacement System $200.00 a�� � � e O <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ ,i�c�� � <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />