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F � CITY OF PRIOR LAKE
� ,� SEWER AND WATER PERMIT
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�. ��� File pERMIT NO.
2. Yellow City >Z ,,. ���
3. Gold Applicant �
ease or t and si at bottom
ADDRESS ZONING �otr�,��
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LEGAL DESCRIPTION (of�ice use only)
LOT BLOCK ADDTTION PID
OWNER
(Name) I� � ��'� vQr�� � I`a P e� S. (Phone) �° l�' ^ g63 - �SQD
(Address) J Q n�-�- -
(Address) (City) (Zip Code)
APPLICANT � ) _ n _ �,t °� 5 �- cf [E � •- 3 D U �
(Name) �� A-1 � 2N � c,-�. �o• . �-- _ (Phone)
(Address) �Y7 � � �un0.'fi1�.4-.� U � �' 7' � h�iS � , /'►'� �J � � 1 �
(Address) (City) (Zip Code)
(Contact Person) 'C � � S O � (Phone) � � a - � 39 ^` �S .S � v
APPLICANT SIGNA � 3 �
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'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 $ ,j I- .�
STATE SURCHARGE $ — � ^ v� - - U n�0�
TOTAL PERMIT FEE $ � b . ,h�
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid �/ �-� Receipt No. �/
(0 �E7
Date � ` /� By !
Buildins Official Date
The Minnesota Statutes § 3 26g,148 our notice for all inspections (952) 447-9850, fax (952) 447-4245
"SURCHARGE" has been extended 4646 Dakota Street S.E., Prior Lake, Minnesota 55372
until June 30, 2013,
The minimum surcharge for a
"fixed fee" permit is $5.00