HomeMy WebLinkAboutSewer/Water Permit 12-0039 - 0O
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RIO P Date Rec'd
/tee, : � CITY OF PRIOR LAKE
Q17 f t77 SEWER AND WATER PERMIT /, C i. IL
41 I/8NESO
1. Green File PERMIT NO. �Z 3
2 Yellow City
3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
"77 AA/N<) - {'ru;1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER L, 9Sz- Viz - 7Y (Name) S L -h- U n ( P hone)
(Address)
(Address) (City) (Zip Code)
APPLICANT ff ..
(Name) r : I Pleo� � 11 � J U5 ``4 T1r f CJ (Phone) 40 S-1 ' 4 ; 4 4 5 -- 0(02
�a
(Address) 143 L `"P� 20mc. S .i'• I P Gt 0 1 s -5 1( 1
( ddress) (City) (Zip Code)
(Contact Person) S (Phone)
APPLICANT SIGNATURE DATE 1 / q
- 20 )
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 #
The Minnesota Statutes § 326B.148 :R AND WATER PERMIT FEE $ Z `J" . SZ7
"SURCHARGE" has been extended 'E SURCHARGE $ 5 Cl2A
until June 30, 2013, U., PERMIT FEE $ ? Q, _Cb
The minimum surcharge for a
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid b S� fipt No c/ f
Date �/ 7
Building Official Date 1— { - 1 �---
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372