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• <br /> ** ATTENTION APPLICANT ** <br /> Fill in all appropriate blanks and check all appropriate boxes. <br /> I will be installing the following: <br /> a ks <br /> Precast Concrete n Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <br /> Size of Tanks: /300 13Oo /3b0 <br /> Treatment System <br /> Trenches s.f. <br /> X Mound i3o s.f. )ox43 —4/3l( ove,czt;l) <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 co ^= *� <br /> Signature of Applicant )' c•�: Date: <br /> MPCA License No.: I "/ <br /> Staff Review: r,Accept ❑ Deni d ? <br /> Reviewer: Date: ? "49"—/ .l <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): ReyV1.; . dam' F <br /> __o , Seri n cr. -O ,/Uf? r 5 1 (3d r weft . <br /> Reset Form <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 / 2 <br />