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°pRI� Date Rec'd
' r 'e • CITY OF PRIOR LAKE
SEWER AND WATER PERMIT •
r.o?.
Getlow reen F ry PERMIT NO. vq 0 ( 9 5
Y
3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
2 11 V P\ EC,s -\---- -, Th- E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) , ' 3 (N AA \ C ` �! ` ‘C.. k- (Phone) 5 -; _tit i 1 `3 �,�
(Address) _ ` 1 ( ? WS * N:' La VA 55- 3W
(Address) (City) (Zip Code)
APPLICANT 1' . .-- (-�.
(Name) `CUQ A(' G C ( \ \Il .NRC•. (Phone) �� e)-q - V `5
_ i \-15—..-'4 C f
(Address) 15 I J� � C�OC LOA 5� i
(Address) (City) (Zip Code)
\
(Contact Person) �` 0ti� -C- (Phone) 9
APPLICANT SIGNATURE ` 1_ '"� DATE - -.- 30 -0
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. N k ❑ ABC ❑ PVC ❑ Cast Iron
Estimated length of sewer line feet. NA
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,1 b cost with a $51.50 minimum
Sewer connection only $25.50 `Water connection only $25.50 .
- D �i
Estimated Cost $ \ Building Permit #
q_?-c, ° l SEWER AND WATER PERMIT FEE $ J J ' D
-- STATE SURCHARGE $ .50
� � _
TOTAL PERMIT FEE $ 1j .1)0
S/ 5
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 26 ' o Re tNo`f,N_
Date
Buildin¢ Official Date / 9 . 9 U .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372