HomeMy WebLinkAboutSewer & Water Permit #12-373 N ❑ ❑� (� ❑❑❑❑O❑ 'v O D yc�
� � 2 ��� 3 mDC�cO m � m n0
o � o ��� 3 r 3 z-a Z � t� �+
t�i r- � m m y m t S=D O tn O�
�, � � y Z �v ��� z�
to � � n a N � Z z p�
� -i -�
� '� n � � Z m �
0
m
� , Z � �
� r o � �. �l`�
� v v �� �.
�' � o o � 00 O❑❑ �
�' m m � y�, 3v 3v
'�f m m m mc ymc
� o � � v o � ��'"� o� m O � �
� C ' � � z�xx�� 3 - ��. m
� m `�. ��, o o �-� � c� v
b� o z � Z �� z m
� Z � m �i ��� O �`" v
1 � Y` �
� A o �' � �
� Y m
� � o -� J
� < ❑❑ 000 � �
�
Z m '� - � � � �
� D � ymm3c�i , m
�' > m�S�o 'u'�1
'� Z ��g� r
� � ��A�� �� �
N 2 - Z � � m
� r G� [4.
n
�,
o s� rRjo� Date Rec'd
� �. CITY OF PRIOR LAKE � � � �
� ,� SEWER AND WATER PERMIT
�jNNES��A ,
1. Green File pERMIT NO. 3
2. Yellow City
3. Gold Applicant
lease or ' t and si at bottom
ADDRESS ZONING (oflFice use)
l6 � Dv � 5� �
LEGAL DESCRiPTION (office use only)
LOT BLOCK ADDITION PID
OW1vER
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICAN 9 s�- - y��- 3 � o�
(Name) Ar t�f?u .— � : cr'� �c� - r �--ne - (Phone)
(Address) / y 7 � - ��c� r�� �� �a � 1�7 � �+ c� :t� � , �' � 4S 1 Cct. 1'v1 �V �'S � � �
(Address) (City) (Zip Code)
(Contact Person) �-�� � (Phone) !a / ,�- - � 3 � ' ��� V
APPLICANT SIGN DATE '7 �
APPLICANT PLEA5E 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 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 #
The Minnesota Statutes § 326B.148 �R AND WATER PERMIT FEE $ �- J'��- -s�
"SURCHARGE" has been extended 'E SURCHARGE $
until june 30, 2013, �L PERMIT FEE $
The minimum surcharge for a
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid 3 G ,� Receip o. � r�3/
J
Date� �, l Z By
Buildin¢ Oft5cial Date �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372