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CITY OF ORONO APPLICATION FOR UTILITY PERMITS <br />Box 66 (1335 So Brown Rd) SEWER WATER WELL <br />Crystal Bay, MN 55323 <br />Gawral last. actioss <br />1. You may apply for utility permits by mail or in person at the City offices. <br />2. Mailed in applications are subject to the ,ostage and handling fees shown below. <br />Permit cards will he sent by return mail the same day the application is received. <br />3. Permits are not valid until you receive a permit card. <br />4. Work must not begin finless the permit card is available on the job site. <br />5. Utility connection permits may be issued to licensed contractors only. <br />6. Contact the City offices for utility stub as -built locations. DO NOT EXCAVATE IN ANY <br />STREET AND DO NOT TAP ANY MAIN without express approval of the Public Works <br />Department. Issuance of a permit does not grant this approval. <br />7. All work must be done in accordance with State Code requirements. <br />S. All work must be inspected before it is covered. Call 473-7357. 24 hour notice <br />required. <br />ttffflfffffffffffffttfRltffffft!!fflfttlfftffffflfflftflttfftt!!lftttf!!ft! <br />JOB BITE ADDRESS: I-14 2) - F ,F o'E 9-#.:)C- SS P O! tiT I� <br />Occupancy Type: _ Residential _ Commercial <br />OM , 8 BARE: 5LLA. •- 01"-b LkA r3 NcA-r..5 v C. Phone No.: %.k- r11e <br />Mailing AddressCJ!5 LA- b��('fir f City: f,i_00r"M)to -oN <br />: S' zlao <br />COBTBACTOR IS NAME: R" yKO "O E • 014� (o P LP(a -la: C- Bus. No . • V fo to - (O a") d <br />Mailing Address: gajfo CJ.7:Q&y= " !�tQ City: R(CFh f T t�-t.p <br />Master Plumber's Str.te -,icense No.: -OP ity Cert. No.: <br />ffefffffffffffffffffffffflfftttlffffT+F"�F�i�i�t-Ti'iffftflffffffltflffffffffft <br />PERMIT TYPE AND FEE CALCULATION <br />MINICIPAL S1 10 CONNECTION ($30.00 per stub) $ <br />pipe size inches; material PVC (on sand fill); cast iron <br />SAC Charge 550.00) mu3t accompany all sewer permit applications unless <br />prepaid. If not prepaid, a sewer connect'—i permit will not be issued. <br />MUNICIPAL WATER COMNNCTION ($30.00 per stun) $ <br />pipe size inches; material ti copper; other <br />WATER METERS must be picked up and paid for at City Hall. <br />(5/8" meters - $95.00; 3/4" meters - $130.00) <br />PRIVATE WELL IBSTALLATIONS ($30.00 per job) $ <br />Check: New Replacement Repair Adandonment <br />Casing size: inches <br />(Installs on of new/replacement well covers abandment of old well, <br />Well Abandonment - not concurrent with installation of new/replacement <br />well requires a separate permit) <br />REQUIRED minimum setbacks from drainfield and septic tanks - 75' <br />CALL FOR A SITE LOCATION BEFORE DRILLING <br />Upon completion, City must be sent a copy of State Well Record. <br />tf!lfffitffffttltlft!!!*ttttlflt!!lfffttffffAAftftftfffffttfffffttttlflftlf <br />1. Subtotal of above permit requested $ <br />2. State Surcharge .50 <br />The State Building Code Division Surcharge o .50 per permit must be <br />included for each well, sewer and water connection permit requested. <br />3. Postage i Handling (Only mail -in applications) $ 1.50 <br />4. TOTAL PERMIT FEE (add lines 1-3 above) $ <br />fffttttffftffttfflfffttlf!lffftltofltfftlfffffltflttlftltffff!!t!!ltffff!• <br />The undersigned hereby applies to the City of Orono for issuance of a utility Permit, <br />agrees to do all work in strict accordance with the ordinances of the City and the <br />regulations of the State of Minnesota, and certifies that all statements made on this <br />application are complete, true and correct. <br />,7 <br />Signature of Applicant:p,_, /) {. '» *14; lr %Vc�: Date:: ? A <br />NOW <br />