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• <br /> 5; q3 <br /> �4o� City of Orono •RCI USE ONLY p <br /> - // P.O.Box 66 d <br /> 2750 Kelley Parkway Date Received. I 10 PerMit# c�Gll:� 4 <br /> yL. <br /> ct.. <br /> Crystal Bay,MN 55323 <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 /> Site Address: 1 3 3 S ( )c )-}-No ft'- bR <br /> T <br /> Owner: J I r" /4-etAvk e—%" Mailing Address: 5.414,e <br /> City: Zip: 3 2 3 <br /> Home Phone: Alternate Phone: (a( 2. - 7 S I — 7 Co-7 5 <br /> nithd <br /> r <br /> S <br /> Contractor/App.: ( �-j � 5 {- Contact Person: E t^ <br /> Address: Z(-3 �`?� ST 5 State License #: 1-6o4"O (6!f <br /> City: /11`"^-1-75 Zip: S-53 ''3 Expiration Date: ZG I z <br /> Phone: 7G 3 ' (4.7f_ ( 76 � r <br /> Alternate Phone: (t• 2- 6 5 SS 57 <br /> TYPES OF OCCUPANCY <br /> Residential ❑ Commercial ❑ Other <br /> " " PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 Z_ <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ ZO <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />