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Date Rec'd
°� " PRI �� CITY OF PRIOR LAKE /
�' � � SEWER AND WATER PERMIT `�' � � � /
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� �� File pERMIT NO.
2. Yellow City I / ` � � � �
3. Gold Applicant .�
Please e or rint and s' at bottom
ADDRESS ��� �� 5 �� L ZONING (office use)
� C.��Z �1 �� S .�2 �G ��(l o �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) � (Phone) � lX � ^ � �� � � � I �
(Address)
(Address) (City) (Zip Code)
APPLICANT �, a (,�`� (� ¢??
(Name) ��u Q.�� ��GwUG, '��1 (Phone) / '' C � �"/ �- 0 J J �
(Address)� � ��! � 6- � �El l� C L�,`u �� �� J � �-
(Address) (City) (Zip Code)
(Contact Person)��'t (Phone) �— Z`1 Z` b ���
APPLICANT SIGNATUR DATE I�� � J'" I� _
I
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.
FEESCHEDULE
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 $ 2�. �U
STATE SURCHARGE $ S',, cs:�9
TOTAL PERMIT FEE $ '3 C, _ �"Z>
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 3 � �' Receipt No. � ��
Date� /`�-. // By
Buildin¢ Official Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372