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L <br /> v.04. City of Orono FOR CITY USE ONLY <br /> 0 Q P.O Box 66 <br /> 2750 Kelley Parkway Date Received: h/13 Permit# 20 13 (,J i q <br /> 5 Crystal Bay, M0N 55323 <br /> CI ` <br /> (952 249-4600 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 /> Job Site /Owner Information: <br /> Site Address: (P(P5 ()rcJicrd 4(__ i&t- <br /> Owner: <br /> 1 I(I`CvU1 ''i ►' I of I j lay yid UIS Mailing Address: SCt/VYI -- --- <br /> City: U n.9, L&/L ; OAZip: c [O <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant Information: <br /> Contractor/App.:40 l K6 S (-4)El g C- Contact Person: Pawl. o f 61en 441raie- <br /> Address: <br /> anI `� (Lt,'"LeAtta lam' 1 State License #: (---/C1r9j C1'1't Pen) <br /> City: f4C).11,b(/ Qiv- Zip: �3 LJ / Expiration Date: LiI(.P /i ?,_ <br /> Phone: !L?' 44-9S7-0 02 Alternate Phone: <br /> [ - — ICY <br /> /,/,5-e C a- U- <br /> Residential kviJ ] Other <br /> bui r _ v <br /> \ 1/ EES <br /> 7't6L°6dlS <br /> New or Reply 6O. 00 <br /> , t <br /> Repair Existi <br /> (Tanks or D <br /> State Surchz G 3 , ` -q ,R,dq 5.00 <br /> Total (03 . <br /> LJ� i $ o5. 00 <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />