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P_Rip Date Rec'd
CITY OF PRIOR LAKE
SEWER AND WATER PERMIT
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2 v iioW cty PERMIT NO. l/ l
3. Gold Applicant r `
(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
OWNER 04 / •
(Name) � '` G ? -- cA 1 (Phone) ( L1 19 - —1 3 ]
(Address) hi 8 L �L' >'� p X37 z,
(Address) (City) (Zip Code)
APPLICANT r L c _
(Name) l �..() Qr O` f l hone) / J Lp7 0 3 S
(Address) VU , :.: 7 (\ t G:l t 1 P 5r 3 7
(Address) (City) (Zip Code)
(Contact Person) C (Phone) cr Z ` 0 1
APPLICANT SIGNATURE DATE " / 1
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APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC 12 ❑ Cast Iron
Estimated length of sewer line 1Q feet.
Clean out (if required) located at j 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 $ Z S. 3
STATE SURCHARGE $ .U 28.0
TOTAL PERMIT FEE $ 3 O S
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 3o sl Recei', o. 070
Date q % S / r By 4
Building Official Date ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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