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CITY OF PRIOR LAKE
ci' SEWER AND WATER PERMIT
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1. Green File PERMIT NO G
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2 Yellow
3. Gold d Applicant
City
pplicant / I
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
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(Name ) A- O\O' v \ "v (Phone)
(Address) C M:1qL A, \6 N St, , V L 5 C3 7 L
(Address) (City) (Zip Code)
APPLICANT j
(Name) \ (\) Q-�4J CxGCW0v (Phone) / s7' fi - 3
( Address ) I r/ 5 .-- -4 14 5+ E � (� �) r (.._G )� S37 Z
(Address) (City) (Zip Code)
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(Contact Person) G (Phone) 1sz - "1 �l - ��3 ) �
APPLICANT SIGNATURC .I_li DATE 5 r �
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC ZPVC ❑ Cast Iron
Estimated length of sewer line ( O feet.
Clean out (if required) located at feet from structure.
FEE SCHEDULE
Residential sewer and water line connection $51.50 Industrial, Com'I & Multi- family 1% of job cost with a $51.50 minimum
Sewer connection only $25.50 Water connection only $25.50
Estimated Cost $ Building Permit #
SEWER AND WATER PERMIT FEE $ 25 TO
STATE SURCHARGE $ 5. 0.4
TOTAL PERMIT FEE $ 3o • SC-
(Office Us. Only)
T * i' ti on I s • i r Bu ilding P rmit When Approved Paid Receipt No. 65153
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/ A _ 7 28 // Date
B Date ��
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372