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r <br /> FOR ITY SE ONLY <br /> 0 1- City ofizaY <br /> ��Rece�Ye�� ° � � ���� <br /> �{ CryBa ,MN 55323 <br /> f� (952)stal 249-y4600 /(1// <br /> Amount: $ <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 /> Site Address: 51-10 0 l 0 Qyq .t c3qRd. Eco <br /> Owner: c4w.c.,S d )-le`;�i L3�\\ �� ' Mailing Address: <br /> City: 0¢.01-,t, Zip: <br /> Home Phone: Alternate Phone: <br /> ortfracPAPR'19,0911,91-WWIR <br /> Contractor/App.: 11,0-L\ne�c+e Contact Person: CS r.rQ -` <br /> Address: 12_069 u31.;.\.cA 1•tv State License #: -19 Z <br /> City: }\AHbUeer_ Zip: SS—sag I Expiration Date: o4//2- <br /> Phone: <br /> 4//ZPhone: `7(3 J-1c6-ail CMZ__ Alternate Phone: `7103-2436-2)-10Z. <br /> !►:i Residential ❑ Commercial _ Other <br /> New or Replacement System $200.00 c;;;:?o1, <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ 07.0i. <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />