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A <br /> ** ATTENTION APPLICANT ** <br /> Fill in all appropriate blanks and check all appropriate boxes. <br /> I will be installing the following: <br /> Tanks <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <br /> Size of Tanks: f 3Co 1300 /3OO <br /> Treatment System <br /> Trenches s.f. <br /> Mound q66 s.f. 6O 3b 4 F4— <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 of Orono 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 corr;,c <br /> Signature of Applicant Date: /0-/7--// <br /> MPCA License No.: 019 Z <br /> Staff Review: I1' Acceptf�f��j❑ Denied <br /> Reviewer: w�,►r'% VJV-r Date: /0 ' ' 8 <br /> 4 1 <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 />