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� ,��� City of Orono R ITY USE-0NLY i <br /> P.O. Box 66 Q� �� <br /> �n$, � 2750 Kelley Parkway Date Received. U �� Permit#�l�`� � <br /> � �r��. Crystai Bay,MN 55323 -� ''� �'C,' <br /> ���i�$c� (952)249-4600 Amount: $� <br /> e <br /> CITY OF ORONO - SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building O�cial) <br /> �� ��.' � , <br /> � <br /> � , n �-E c�� 5� �c�o l ��ov S� <br /> ��b� ite"`� v�ra� .� rmation: , � � <br /> �� � <br /> � � . , . .. .:� ,.� t. . � <br /> /� � � <br /> Site Address: ci, /�� . /O/17-r3.3��� 1�� <br /> /� <br /> Owner: �i�t t�(•�/e / Mailing Address: � <br /> City: ��`�'v1� Zip: `7 �J �G/�l. <br /> Home Phone: Alternate Phone: <br /> ���� �.�+ � : <br /> Contractc� �/� , p' ����`,; <br /> �� <br /> Contractor/A �to1 � d� L XC c� ���r��'� Contact Person: �� �2 � <br /> Pp�� ���r 6'1C � s <br /> Address: �(�� ��c;t;��'��c�c�' �� �%i�tate License #: �.�r �j � <br /> City: IUc�r�t,✓an�{�� „�Zip: � ^ .�.� Expiration Date: �"' � � <br /> ' � �4'/� C c <br /> Phone: -(, j�,' �Gy�� 3 `��� 7 �" Alternate Phone: <br /> z�`:� .�x ' A . � F i s 1Y��f'' ES'�L)�'��CU�?�IC���.; �"' � ` �'� � � �� , ����� �.t�� , ����� � <br /> �,� � � � <br /> � ,� � � �� � � � <br /> . , rP,.. �. � ..`�°.,, ,�.a ..�ir:,. e b i t t . I. .rS„ :.. <br /> , . ,.-m" 1 ,�` `",� ..y. <br /> � Residential ❑ Commercial ❑ Other <br /> / ' <br /> � PERMIT TYPE AND FEES ; <br /> New or Replacement System $200.00 �' t�.(,�L�� �; (,�` <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ ���` �� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />