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i���.---� . _ <br /> I� SKETC�: Submit licensed site evaluation, design, sketch �nd management pian with <br /> � a�pplication. If substantial changes are made to the design during installation, a new design <br /> �j�� must be submitted with the date and designer's signature prior to instaliation and inspection. <br /> Compieted Site Evaluation ' es :�No Date <br /> Completed Design Worksheets �'S'es �No Date _ �__�._ <br /> Compliance Inspectian ❑Yes JNo Date <br /> Management/Monitor Plan as ..lNo Date Approved � t <br /> �� <br /> � <br /> j AGREEMENT: I/We the undersigned. hereby make application for work described and located <br /> � as shown herein. !/We certify that the informatian contained herein is correct and agree to do <br /> the work in accordance with the provisions of the Orono City Code and the State of Minnesota <br /> MPCA Rules 7080-7084. I/We further�gree that any p{ans, specifications, or drawings <br /> su�itted,�ierewith are acc ate and come part of the �pplication. � <br /> �� , ����,� r / � � <br /> I' -�'`�, 1 i.. � �t_ : � I <br /> �I� Si r� e of Homeowner or Agent Date : <br /> 9 .__—__-----------� <br /> !; PERM/T; Permission is hereby granted to the above named applicant(s) to perforrn the work <br /> �� described in the above application Any and a!! changes to the approved design shaN be � <br /> �� reported to the tfesigner and to the per+�nitting agency prior to the completion of#he work. This <br /> pefmit is granted upon the express condition that the person to whom it is granted, and hislher <br /> agent, emplayees and workers shall conform in all respects to the Orono City Code anci the <br /> State of Minnesota 7080–7084 Rules. This permit may be revoked at any time upon vioiation <br /> of said ordinances and cades. Tf�is permit expires on December 31 of the year in which it is <br /> ( issued. This permit, with all supporting documents, will become a permanent part of the <br /> property records on file st the Orono City Hall. <br /> 0 / <br /> Community Development � ctor or Designee ate <br /> � <br /> Return this Application tn: <br /> Phvsical Address: Mailina Address: <br /> City of C)rono Ci:y of E3rono <br /> 2750 Kelfey Parkway P 0 Box 66 <br /> �rona, MN 55356 Crysta� Bay, MN 55323 <br /> Phone :952-249-4600 www.ci.orono.mn.us <br /> Fax� 952-249-4616 amacicCa�ci.orono.mn.us <br /> Se�tic Permit—Revised 7/8/2014 F'age 2 of:3 <br />