HomeMy WebLinkAboutS/W (repair) 07-0079
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
Date Rec'd
Z Z ( ('7
(Please type or print and siJUl at bottom)
ADDRESS
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LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
OWNER
(Name)
(Address)
(Address)
APPLICANT I
(Name) L' 6 '7.~ E .,1(( .:'_./4r- \5 ...L/t/e-
(Address) /817 ~)"a,:".,~/ L.c..r,c
(Addre'ss)
(Contact Person) /1'}A "I / /'/;'n-fJ <;
APPLICANT SIGNATURE ~. ~ ./
/
~ ~~;::'w ~ii~~. I PERMIT NO. /'.7 00'--'01
J. Gold Applicant ~,. 17
,
ZONING (office use)
PID
(Phone)
(City)
(Zip Code)
(Phone)
95d.. - ;22 Y - St:>'jO
frYl~ ,~S3 5- Z
(Zip Code)
&/:l- -917 -1t.SS-
~- ;:? / - 0 7
7;;. .,.- t:'/~__
(City)
(Phone)
DATE
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. D ABC D PVC D Cast Iron
Estimated length of sewer line feet.
Clean out (if required) located at feet from structure.
Residential sewer and water line connection
Sewer connection only
FEE SCHEDULE
$35,50 Industrial, Com'l & Multi-family 1% of job cost with a $39.50 minimum
$17.50 Water connection only $17.50
Estimated Cost $
SEWER AND WATER PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Your Building Permit When Approved
Building Official
Date
Building Permit #
$
$
$
I / ':> C
.50
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Paid 1&, ()V
Date
2- 2- I. {,'7
Receipt No.
B /
y/
~25 711
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245 0