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CITY OF ORONO * z 0 1 2 - B 1 1 9 7 * <br /> • 2750 KELLEY PARKWAY DATE ISSUED: 1U27/2012 <br /> ORONO, MN 55356- <br /> (952) 249-4600 FAX: (952) 249-4616 <br /> ADDRESS : 2590 COUNTRYSIDE DR <br /> PIN : 04-117-23-11-0010 <br /> LEGAL DESC : COUNTRYSIDE MANOR 2ND ADDN <br /> : LOT 002 BLOCK 002 <br /> PERMIT TYPE : SEPTIC <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : REPAIR <br /> ACTIVITY : MOUND SYSTEM - SEPTIC <br /> NOTE: TEAR OU'C AI3SORP"1'ION AREA,SAND AND ROCKBCD AND Rh:PI,nCG <br /> APPLICANT SEPTIC RGPAIR 100.00 <br /> HAYES& SONS EXC. WC. STATE SURCHARGE SEPTIC 5.00 <br /> 263 82ND STREET S.E. TOTAL 105.00 <br /> MONTROSE, MN 55303- <br /> (763)479-1762 PAID WITH CC# 5293 <br /> Minnesota State License#: L640 <br /> OWNER <br /> LEWIS, JOHN& ELIZABETH <br /> 2590 COUNTRYSIDE DR <br /> LONG LAKE, MN 55356- <br /> AGREEMENT AND SWORN STATEMENT <br /> l'hc���urk for which this permit is issued shall be perf��rmcd according to <br /> the approved plans and specifications,applicable City approvals,and the <br /> State Building Code. This permit is for only the work described and docs <br /> not grant permission for additional or related work w�hich requires separate <br /> permits. All provisions oClaws and ordinances goveming this type of�work <br /> shall be compicd with whether or not specified herein.This permit���ill <br /> c�pirc and bccomc null and void if construction authorized is not <br /> commenced within 180 days of the date of issuance,or if construction is <br /> suspcnded for a period of 180 days at any time after work has commenced. <br /> The applicant is responsible for assuring all required inspections are <br /> requested in conformance���ith the State Building Code.This permit may be <br /> oke ti ie for due cause. <br /> /l � z7 � l�- lC � a � a— <br /> Applican ermitee Signaturc Date Issuc y Signature Date <br /> SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. <br />