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> <br /> g0� City Of Orono � FOR CITY USE ONLY <br /> G � P.O.Box 66 �� �D/� <br /> +��t 2750 Kelley Parkway 1 Date Received; �� Permit# � O •3 �� <br /> : �a� t��i��. � Crystal Bay, MN 55323 � <br /> ����g����o (952)249-4600 � Amount: $ <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 /> � <br /> Job Site/ Owner;ln���mation. �u� �.�� �=`� �-e ��' '�-� � �5�� l��� <br /> , ,:.�--��-- , - <br /> Site Address: ` � !� `� , ►�-�-� ✓-c� ��. ,.,-�?. <br /> Owner: 1� ! � �Z° I� �4-�„e�, "X �^='� I���-�"��5 Mailing Address: <br /> City: C'� �r2-�s�--. � Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/'Applicant In#ormat�t�r�„ ,� . <br /> � �� �.���-.. � .���� <br /> ,� ` <br /> Contractor/App.: �1� ��' S � S ��� Contact Person: - ��'� � <br /> � � <br /> Address: � � � � z- S'�f � � �`� State License #: �-� �� <br /> City: �� 11'���� z�p: 5�3� �3 Expiration Date: 1 I - � � � � <br /> �x l' <br /> Phone: 7 � 3 �� 7`7 ` � �� Z- Alternate Phone: � /� -Co ��—`�5�� <br /> � �" � �_ � � � TYP���� ��C:CUPANCY ��� �� �� ��� � � �, ,n �.�. <br /> � ,. .y: <br /> . <br /> ., . � . <br /> � . ,�. � <br /> , <br /> �. t. � �,z. , , . <br /> � Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES ` ' '' <br /> New or Replacement System $200.00 ��.. �� <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> v-� <br /> Total $ Z � � '"— <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />