HomeMy WebLinkAbout1987-05-12 App. & Permit, Water Well #9004GENERAL PERMIT
CITY OF ORONO
CITY PERMIT N? 9004
P.O. BOX 66 Date
CRYSTAL BAY. MINNESOTA 55323
(612)4773-7357
Owner �(c ,1 ! , l wry t ,� 7 Address
Contrttctor LO Address`��cz� =�
City Ikense No. City fill
(Ale
.
REMARKS AND SPECIAL CONDITIONS
PERMIT TYPE AND FEE:
Inside Plumbing (#fixtures _
Water Meter (Sine )
Meter #
Remote #
Municipal %ter Connection
O Copper O
Municipal Sewer Connection
O PVC C] Cast O
%IWCC SAC Charge
On Site Spetic System
ACKNOWLEDGEMENT
"\ NEW
Fee S
Fee S
Fee S
Fee $
Fee S
Fcv S
'ITtt• undri,wrttd htnM ackrn,wkdgt% rtttipl of the limited permit.
,ndiitltr* uvovmr of all .Rtnl tnfornumm. term.. totdnu,m o,
r yuirrment, Antlen aM„r lire undempncd under und% and agree,
urrk•r pemdn A law that tht. permit n yrrllt limn d in v',Kr to the work.
.1101%nl% „r improtrmrrrt 'tiered: that thn Irrmn der. not grant am
autM�nt� to ck, work or wittlin ntyunnnp wrierar Ivrmn appro,al,. and
that lho prrmmikr, rw,Igramaudwvntt t„,tohk am pnoot.uxn,fait ( n1,
onlirtantr tx tine law. rule or regulation All work .hall tv d<• in %tni t
'I mrillantc wqh all Citt ordtnark: , huiklirtg u,tlr+ and, or health
tk-Mrtmtnt ngukttuxt,. and .hall lv a*gmt it, tmpnvon. apprmal or
relmlion ht the Co Whrrv,rr v, ordertd. the urdermped agrtxN to
oureo am w,wk fount to tv in %liblio n o(1hc condmom o(thn ptrmtt
Signature of Applicim
' "�C `fir t /��l��i' �`•- S�r,�`'
❑ AD[
)ITION ❑ REPAIR
Water Well
Mechanical Equipment
Fireplace/ Wood Stove
Moving/Lifting Buildings
Land Alteration (Excavation.
Grading. Filling, etc.)
Design Review
Fire
Sprinkler System (Fire)
Other.
After -the -fact Investigation
O REMODELS
Fee S
Fee S
Fee S
Fee S
Fee S
Fee S
Fee S
Fee S
Fee S
Fee S
TOTAL.
State Surcharge: Fee $
Total Amount Paid to Citv Fee S - L
This permit is not valid until the proper fee is paid and it i< approved
by an atltM)ri7Ld City Official.
Signatur ,4 City Ofihrhal
Calk: While- File Cttpy Cann InsMim'c Copy Pink hnanur Copy rk4d Applicant', Recttpl