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.r"' <br /> � � <br /> � g0� City of Orono FOR CITY USE ONLY <br /> 0 t\ � P.O. Box 66 <br /> �,4 2750 Keliey Parkway Date Received: Permit# <br /> � 1�'��. t� Crystal Bay, MN 55323 <br /> ��.,,�;o,��,�� (952)249-4600 Amount: $ <br /> � <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'�C)�ntr�e���n�� i ��m � <br /> ,���. ���.. .���.�� <br /> Site Address: `f' � �(� 1'U��-��, ��h, /,7�- V�� <br /> Owner: ��'��1/�" l�� ,� e�- � Mailing Address: <br /> � <br /> City: `1�G`J n C� zip: 5 S 1� �I <br /> Home Phone:�;�',;�--- y 7� - .��� `�' Alternate Phone: <br /> Contractor/Applicant Informatian: ��"��;� <br /> Contractor/App.:��J'1�,,;�� �x c:�,;,�, �, ;��, Contact Person: ���1�1�vt�; <br /> Address: 7/,� 5� ���Z �2 is� �?���� State License #: 7�� C�' <br /> City: 1�7�{ � Zip:, S 5 ��G�=' Expiration Date: �._�/D�/;Z��� <br /> Phone: `��5 a�- �ST - �..5�'�i`�' Alternate Phone: � ��-���E � � �>�/ c,�j� <br /> ��M � � <br /> �� �.�.}R� .��,�r ?��. .�� �,°�.,:� ,. TYPES OF �CCUPANCY ., : --� <br /> [� Residential ❑ Commercial ❑ Other <br /> � ,, <br /> � �� ��. ..s...�� � � "Y �.:a� �r,�� ��"�� �.°. �REF�MIT�;��YPE.AND.FEES������. , �,; � ,,� �`�� E � <br /> New or Replacement System $200.00 <br /> � Repair Existing System 100.00 � DD. D 0 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />