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("CpRi � Date Rec'd
CITY OF PRIOR LAKE
�, , SEWER AND WATER PERMIT
li fIi'NESVrs'"
Green File PERMIT NO / �-
Gol Applicant NO./ / . / Li �S
3. Gold Applicant LLL / v �J
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/Z 4 / 7 7 1 .0 /%1 , J r
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) 7 .ee ✓r dJ , /1T (Phone)
(Address) /6 V.�U 25 !//l. i - /4"r SC 1 32e - Z41, - 553 — 7 Z
(Address) (City) (Zip Code)
APPLICA
(Name) (Phone) 7‘%'-- 5
(Address) /957J" 0 7 #,47✓e N T4A4/ -- -S '7
(Address) (City) (Zip Code)
(Contact Person) ` i t L 1 (Phone)
APPLICANT SIGNATURE 4 - — DATE /� _ 5-7,
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC ❑ PVC ❑ Cast Iron
Estimated length of sewer line feet.
Clean out (if required) located at feet from structure.
FEE SCHEDULE
Residential sewer and water line connection $51.50 Industrial, Com'l & 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 $ ZS• cp
STATE SURCHARGE $
TOTAL PERMIT FEE $ 3 U , - 2 1 g
(Office Use Only)
This App Becomes Your Building Permit When Approved Paid . O s -- 0 ec pt No.
/..c >:.L, itibhi Date J .
Building Official Date , ( F.
1 '
The Minnesota Statutes § 326B.148
nu - notice for all inspections (952) 447 -9850, fax (952) 447 -4245
"SURCHARGE" has been extended 4646 Dakota Street S.E., Prior Lake, Minnesota 55372
until June 30, 2013,
The minimum surcharge for a
"fixed fee" permit is $5.00