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** ATTENTION RPPLICANT ** <br /> Fill in all appropriate blanks and check al! appropriate boxes. � � } <br /> I will be installing the following: <br /> Tanks , - s <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other �� �`��'' �' <br /> (list manufacturer) <br /> Number of Tanks: � <br /> Size of Tanks: ` � ��� L� � �o � �uU <br /> Treatment System <br /> Trenches s.f. <br /> _� Mound C� � v s.f. <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 an rrect. <br /> _., <br /> Signature of Applicant �� ' Date: 5� � �- 1 l <br /> MPCA License No.: �� � �� � <br /> Staff Review: c� Accept ❑ Denied <br /> !� /�� ��i�,�" .�- <br /> Reviewer: � � -t Date: � - ( ^1� i � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> � �� �-r�-1 n �C �v��c+� i�.� ���' /��� (�-A i l�:;�= � � ��� �� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 � 2 <br />