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/t PR /04- Date Rec'd
CITY OF PRIOR LAKE 3 19- /Z
° SEWER AND WATER PERMIT
4 rIA'NESDY
1. Green File City PERMIT NO.
2. Yellow
3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 /‘ Co /o /7.9.o.o _CT. j
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER C (Name) ,Oflvc E C/9 ?fie (Phone)
(Address) 7 Z' a` CPI' O4 0 , 1 /00 5 / 1 , 74' /O,1, L f
(Address) (City) (Zip Code)
APPLICANT
(Name) n 70 /20 g 7t /1 (Phone)
(Address) /6 0 4 ,2 7 /9t/f *NV' _ // 17f* ri/
(Address) (City) (Zip Code)
(Contact Person) ,1 /-•‘".. ' (Phone) 7(. .2�G
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APPLICANT SIGNATURE ���` / ../r/ DATE 5 /,
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 sR AND WATER PERMIT FEE $ g.
"SURCHARGE" has been extended E SURCHARGE $ S L. •
until June 30, 2013, U., PERMIT FEE $ 0 9
The minimum surcharge for a
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid 3 5 -- � Receipt o. r Z y q
Date;? / By
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