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, 1. <br /> � �ol���� <br /> � <br /> City Of Orono FOR c USE ONLY <br /> � �0�� 1 750 Kelley Parkway Date�eceived:/ �� 3 ?ertti[#�� ���T <br /> , ICrystal Bay,MN 35323 O-J <br /> {952)249-460D Amou»t $�� <br /> '� ,�`/ <br /> i�� G <br /> ��Kf S H Oo'� <br /> CITY OF ORONO-SEPFIC SYSTEM PERMIT APPLICATfON <br /> (A6 oemuts must be aperoved by the On-Site Sep4c Manage►andlor Buitding Officia�j <br /> Job Site I Owner�nformation: � <br /> Site Add ress: 1S f,� fi..�GC L.� �/�ll�� �/��'�� <br /> Owner: -Zd��v�d �,��,q,e Mailing Address: �A�i�r <br /> City: a�{i p Zip: <br /> Home Phone: Altemate Phone: <br /> Gontrac#ar 1 Applicant Informatian: <br /> Contractor�A L�""11���� _T �T�-�Sp�Contact Person: �i <br /> PP• <br /> Address: �9aZt ���-l�,E 1¢!/E= StateLicense#: 02/9 <br /> City: iL � Zip: /rl/1� Expiration Date:• <br /> Phone: 7�v 3 -- Q?� - :,,Z�� Alternate Phon e: <br /> TYPES OF aCCUPANCY <br /> � Residential � Commercial � Other <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $2DQ.00 �r�0. �� <br /> Repair Existing System 100.00 <br /> {Tanks or Drainfield} <br /> State Surcharge 5.00 5.00 <br /> Total � ,�fi� S. o� <br /> 1N:1(Applications,License w P�nit Applicalims)lPem�its�Septic Perrri i Application-Updaled Surohatge 07-28-11.doc <br /> 112 <br /> Z'd L6ZL-ZL6-£9L �o�uosae;ed•�aewl3 dll�ZO£l9ZdeS <br />