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rI ' <br /> , /�� ��33 <br /> /����\ City of Orono FOR CITY USE ONLY <br /> � 0�� P.O.Box 66 7 20�0-OD,S Z.• <br /> 2750 Kelley Parkway Date Received: !Z O Permit# <br /> � n`'x• �� Crystal Bay,MN 55323 .DD <br /> �;� �'�,;�� ���o��� (952)249-4600 Amount: $ °� <br /> �axo�,' <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: 115 �Ce L►►�e �.idq� <br /> Owner: ��hdakr Cap��t�,l Mailing Address: �hC i alVd� W, s�, IA.OD <br /> c�ty: _Orah�c Ci� , C� z�p: q2��� <br /> Home Phone: Alternate Phone: �1�f'-�I - 7018 <br /> Contractor/Applicant Information: <br /> Contractor/App.: boh�1 VV�II �Y1l�Ir1A C0. Contact Person: r rl(I, h <br /> Address: I�I�O t1Ql(�k L.,YI , S�FL. �01 State License #: �d`�'3 <br /> City: �Y �tVl z�p: 5�35Z Expiration Date: <br /> Phone: Q�Jti.�(�5, ��Oq Alternate Phone: ��2.`�Iq• l54{� <br /> TYPES OF OCCUPANCY <br /> �'Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 290, OD <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Totat $ �A�. ��p <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />