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c R p Date Rec'd
�� CITY OF PRIOR LAKE
i',740 i , *4. � , SEWER AND WATER PERMIT
, ,4t51.0„.„
NESo�A
1. Green File PERMIT NO .
2. Gol City PERMIT ( ? . ..? ( _
3. Gold Applicant ` -_ % / �Cl
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
C / ' Ta)C 7r / t/w
LEGAL DESCRIPTION (office use only) �(
LOT BLOCK ADDITION PI 1) J Y - 0 i 4 - 0
OWNER
(Name) j Ir vc f r eJ 1...1— (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICANT
(Name) . {(t - eNCC , rt C , (Phone) 44 /7 S S ----
(Address) . — (,.. " -- i C Pl( `4 4 ,e ►
(A• dress) / (City) Zip Code)
(Contact Person) /� (Phone) c7 ,)" ._ d C a " c3
APPLICANT SIGN ' • V DATE i ' - (....._•
• P ' ICANT PLEASE COMPLET : . OW
Si' - : water service / inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC ❑ PVC n 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'l & Multi family 1% • ' cost with a $51.50 minimum
Sewer connection only $25.50 Water connection only
Estimated Cost $ Building Permit #
SEWER AND WATER PERMIT FEE $ 2" c . c
STATE SURCHARGE $ .50 0
TOTAL PERMIT FEE $ SO. 5O
(Office Use Only) r
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This Becomes pproved fc.p? `Z____
1 c 4 tion
I EW Date By
t'r dine f t at NI d �� ��
- -.- 24 hour notice for all inspections (952) 447 -9850, fax (9 ) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372