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o � rRjo�, Date Rec'd
F y CITY OF PRIOR LAKE
� � SEWER AND WATER PERMIT
�
�. �„ File pERMIT NO. ` v �
2. Yellow City �,— 9 �
3. Crold Applicant
' t and si at bottom
ADDRESS ZONING �ot��,��
S �Y► (9�UOn �.`� J(�t�
LEGAL DESCRIPTION (ofl['ice use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICANT �^
ame) P�ee�•`+��c. �r��s�r�5 ...Lnc ��one) 6s�/'.C`/,��C�.�
ddress) 0 a` �-1 � oc K- �: {�•�.,1 I J /�'/
Address) (City) (Zip Code)
ntact Person) ��S Gh �i s� (Phone) 6/1-- 5' 2' v— S
LICANT SIGNATURE �` ATE o��.3 '/ Z-
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ A.BC ❑ 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 #
The Minnesota Statutes § 326B.148 ?R AND WATER PERMIT FEE $ ZS. �D
"SURCHARGE" has been extended 'E SURCHARGE $ s(3Z�'
until �une 30, 2013, �L PERMIT FEE $ �� . 5'�
The minimum surcharge for a —
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid �a Receipt No� ��
Date a � //� By '
Buildine Ofticial Date 0 f
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372