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� , <br /> (LTpdated 1/5/04) <br /> CITY OF ORONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, MN 55323 y' - <br /> GENERAL INFORMATION <br /> 1. You may apply for utility pernuts by mail or in person at the City offices. <br /> 2. Mailed in applications are subject to the postage and handling fee shown below. Pemut cards will be sent by return mail the same day <br /> the application is received. <br /> 3. Permits are not valid until}�ou receive a permit card. <br /> 4. Work must not begin unless the peniut card is available on the job site. <br /> 5. Utility comiection pernuts may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(952-249-4600)for utility stub as-built locations. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP ANY MAIN without express approval of the Public Works Depamnent. Issuance of a pemut 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(9�2)249-4600, 24 hour notice required. <br /> 1 l- � U���� <br /> JOB SITE ADDRESS: �I^1 O M•n r���K � �_ <br /> Occupancy Type: �(f Residential Commercial <br /> Owner's Name: Uoo�-I��� � ��S Phone Number: <br /> Mailing Address: City: Zip: <br /> Contracto►-'s Name: onlca ��r, . Phoue Numb r: �►5� arJ--7�f� <br /> Mailiug Address: la-o C►•i-�n �2�. v City: (�,n�'i-s�� Zip: 5S 6 <br /> PERMIT TYPE �onnections ❑Repairs ❑Disconnect (Check One) <br /> 5AC Charge (2003 rate $1,350.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer pennit applications unless prepaid. <br /> (If not prepaid, a sewer connection will not be issued) <br /> Municipal Se er Con-e ion/ sconnect/Repair ($35.00 per stub) $ �S� �� <br /> pipe size inches; material �,kS�,�Schd 40 air tested; ✓cast iron <br /> Municipal Water Connection/Disconnect/Repair ($35.00 per stub) $ <br /> pipe size inches; inaterial copper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> Water meters must be set and sealed by Orono Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQUIRED minimum setbacks from drain field and septic tanks = 75' <br /> REQUIRED setback from sewer line = 20' <br /> PERMIT FEE CALCULATION <br /> 1. Subtotal of above pennit requested $ 3 S. �� <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per pernut must be <br /> included for each well,sewer and water connection pemut requested. <br /> 3. Posta�e &Handling (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do all work in strict <br /> accordance with the ordinances of the � y and the regulations of the State of Minnesota, and certifies that all statements <br /> made on this application are comp t , t correct. <br /> Signature of Applicant: Date: o� '�' � <br />