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: / / ' <br /> O City of Orono FO CI USE ONLY <br /> �1. 1�IO P.o.BoX ss I �D/ DI <br /> 2750 Kelley Parkway Date Received:ll � � Permit# � 3 � <br /> Crystal Bay, MN 55323 ��)� Q� <br /> (952)249-4600 Amount: $ '�"'"'J� <br /> a �. <br /> y�. � ,/� <br /> � /�, t�� � 11 -1 �-l� <br /> `�kESH��� I /, L� !,%t' <br /> l��^, <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 Information: <br /> Site Address: � � � �'�� �"� ��- �' � � <br /> � y Mailin Address: � �UZ v (�`�` ���'� <br /> Owner: �'��ti t�s- � 9 �,`,� <br /> , <br /> C i ty: ���� �v► ��`( �.�ti1 Z i p: S'�"—`�ZZ_ <br /> Home Phone: Alternate Phone: <br /> Contractor /Applicant Information: <br /> Contractor/App.: `�t � � w Contact Person: �-� <br /> Address:�� � � �"f S � State License #: �� ` � <br /> City: �7�'f�'S { Zip: 3 �� Expiration Date: / � --�—� `f <br /> , �� ' i <br /> Phone: �� S� " �7� " � 7� L' Alternate Phone: � �Z � � `�S � <br /> TYPES OF OCCUPANCY <br /> 1 <br /> Residential ❑ Commercial ❑ Other <br /> T PERMfT TYPE AND FEES <br /> ��- <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 /> Total � <br /> Z c� � `"= <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />