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w <br /> .1.-1''''' ''''':;) <br /> . ate�a ::V' ,f .',Ki. +j1-7.1',‘;',1'zt „ f;::;i.Y ,$i"tt th'sz-�..'.i'',i..,a.Tat., 's 4'4' a , ''., , ' i k es 'k �S .», t <br /> Fill"in a1J appropriate°blanks and deck all appropriate boxes <br /> I will be installing the following: <br /> Tanks <br /> A Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <_ <br /> Size of Tanks: /5oo7 1 ec..teorl ot..nt /GC76�« / ,/v1 &1-},' - /o <br /> Treatment System , ,,,` <br /> Trenches s.f. <br /> p„. r .qc, f M aA L� S s�{ <br /> Mound s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <br /> The undersigned hereby applies to the City ofOrono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete, true and correct. r� <br /> Signature of Applicant Date: —62 _/`"r <br /> MPCA License No.: 19 <br /> Staff Review: ❑ Accept i ❑ enied <br /> Reviewer: i - _ Date: 1,/5-/f <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 / 2 <br />