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CITY OF ORONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (1335 So Brown Rd) SEWER WATER WELL <br /> Crystal Bay, MN 55323 <br /> *************************************************************************** <br /> General Instructions <br /> 1. You may apply for utility permits by mail or in person at the City offices. <br /> 2. Mailed in applications are subject to the postage and handling fees shown below, <br /> Permit cards will be sent by return mail the same day the application is received. <br /> 3. Permits are not valid nntil pon reoeive a permit card. <br /> 4. Work must not begin unless the permit card is available on the job site. <br /> 5. Utility connection permits may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department (473-7357) for utility stub as-built locations. <br /> DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express approval of the <br /> Public Wozks Department. Issuance of a permit does not grant this approval. <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work must be inspected before it is covered. Call 473-7357. <br /> 24 honr notice reqnired. <br /> *************************************************************************** <br /> JOB SITE ADDRESS: �-S � �-1 C.� '� 5 U �- � �% � /�C� � 1 C /� <br /> Occupancy Type: Residential Commercial <br /> OWNER'S NAME: �C.�c.r�'� r �o��1S'�• Phone No. : � ��, ' � � � 5 <br /> Mailing Address: 7c���� , ,-os �,�J � . City: ;�rr.aKl'r'i� C���cc- <br /> CONTRACTOR'S NAME: /�(�a�k�` C� �;���w�c� ExL• Bus. Phone: <br /> Mailing Address: �/'�e,�, ��[S� �u, rv� City: �'r�.K�Y,u �:;� Zip: 5 � '� <br /> *************************************************************************** <br /> PERMIT TYPE AND FEE CALCIILATION <br /> MIINICIPAL SEWER CONNECTION ($30.00 per stub) $ <br /> Fipe size inches; material PVC (on sand fill) ; cast iron <br /> SAC Charge ($575.00 ) must accompany all sewer permit applications unless <br /> �repaid. If not prepaid, a sewer connection permit will not be issued. <br /> MIINICIPAL WATER CONNECTION ($30.00 per stub) $ <br /> �ige size inches; material copper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> (5/8" meters = $111.30; 3/4" meters = $146.28 ) <br /> Water meters must be set and sealed by Orono Water Department (473-7357) <br /> upon completion of ineter installation. <br /> PRIVATE WELL INSTALLATIONS ($30.00 per job) $ <br /> Check: New Replacement Repair <br /> Casing size: inches <br /> REQUIRED minimum setbacks from drainfield and seFtic tanks = 75 ' <br /> REQUIRED setback from sewer line = 20 ' <br /> CALL FOR A SITE LOCATION BEFORE DRILLING <br /> Upon completion, City must be sent a copy of State Well Record. <br /> *************************************************************************** <br /> 1. Subtotal of above permit requested $ <br /> 2. State Surcharge .50 <br /> The State Building Code Division Surcharge of .50 per permit must be <br /> included for each well, sewer and water connection permit requested. <br /> 3. Postage & Handling (Only mail-in applications) $ 1.50 <br /> 4. TOTAL PERIrIIT F$E (add lines 1-3 above) $ <br /> *************************************************************************** <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, <br /> agrees to do all work in strict accordance with the ordinances of the City and the <br /> regulations of the State of Minnesota, and certifies that all statements made on this <br /> application are complete, true and correct. <br /> � � s � -� � <br /> Signature of A�plicant: �1--.�� � Date: �j � _5 � `%�� <br />