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��\ CITY OF PRIOR LAKE
�/ 1� SEWER AND WATER PERMIT
... .... �
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. 1. Green File pERMIT NO .' /�
2. Yellow City
3. Gold Applicant �'
Please e or rint and si n at bottom
ADDRESS ZONING (oFfice use)
3715 Island View�ad C�C =
LEGAL DESCRIPTION (office use onty)
LOT BLOCK ADDITION PID
OWNER
(Name) Forest Graser (Phone) _612-716-4431
(Address) _3715 Island View Road _Prior Lake 55372
(Address) (City) (Zip Code)
APPLICANT
(Name)_Krueger Excavating Inc (Phone) _952-447-8835
(Address) _P.O. Box 729 Prior Lake MN 55372
(Address) (City) (Zip Code)
(Contact Person) _Nate (Phone) _.952-292-0154
PLICANT SIGNATURE � l`
� _..,pATE _7-27-2012
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 $ ��.'S�
STATE SURCHARGE $ .5� O
TOTAL PERMIT FEE $ 3��,�Q
(Oftice Use Only)
This Applic io Becomes �our Building P rmit hen Approved Paid Receipt No. �
3m. S'v rp J (O
� �-�C � 2- Date By �^
Ba ' nare � Z(� ► 7t /'+�/
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372