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Date Rec'd
�°� p ��� � CITY OF PRIOR LAKE ��
v � ;� SEWER AND WATER PERMIT ����
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1. Green File p���r�. ��. "� �
2. Yellow City i 1 /'� .�
3. Gold Applicant �
Please e or rint and si at bottom
ABDRESS ZONING (ot'fice use)
5763 Birchwood Ave NE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) _Mark_ Aitkson (Phone)
(Address) 5��� ���'\(lll��� /''�-- � I • � ��`"���'
(Address) (City) (Zip Code)
APPLICANT
(Name) Krueger Excavating Inc (Phone)952-447-8335
(Address P.O. Box 729. Prior Lake MN 55372
(Address) (City) (Zip Code)
(Contact Person) _Tracy (Phone) / ✓ L'" %� �JJ�
APPLICANT SIGNATURE DATE �'
APPLICANT PLEASE COMPLETE BELOW
Size of water service lin 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'1 & 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 $ ��. 5�
STATE SURCHARGE $ 5�� U.$1�
TOTAL PERMIT FEE $ �� S�
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid� �--� Receipt ./_�
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Dat � j c., By
Buildin� Official Date �/ � ( �� Z �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 `