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¢0 City of Orono FOR CITY USE ONLY <br /> O O P.O.Box 66 <br /> / 2750 Kelley Parkway Date Received: Permit# <br /> Crystal Bay, MN 55323 O D� <br /> (952)249-4600 Amount: $ 1�• <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 <br /> Owner:1�0 Mailing Address: 06115 rj�dtfU�, S <br /> City: m ply, zip.- <br /> Home <br /> ip:Home Phone: Alternate Phone: <br /> Contractor/Applicant Information: <br /> Contractor/App.: n1ra) 0LrV&'ffi # Contact Person: v <br /> Address: 69 tL) IAC`) . State License #: j <br /> City: 0C)IrA rW Zip: Expiration Date: Ll <br /> Phone: 4A - L4242W Alternate Phone: �D� —. a%✓47 � <br /> TYPES OF OCCUPANCY <br /> Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 ,f <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ ISO <br /> W:\(Perm its)\Se ptic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />