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Date Rec'd
CITY OF PRIOR LAKE f l l C)
'_-, ;, ' \ SEWER AND WATER PERMIT
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I. Green File , /O PERMIT NO.
. Gol
3
3. Gold d Applicant
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(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LIIC59 � .)--\ - \ec * a�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER `
(Name) 1 {�� (Phone)
(Address) L 1 1 'RU 1 e, 5A- 5L Vc\octal h P
(Address) (City) (Zip Code)
APPLICANT / Q 7 q
033
(Name) � C v� �IJ
U X, O� ( (� (Phone) `1 46 -
(Address) 1 7 175 S — £ Pnbe IA D. 5S
(Address) (City) (Zip Code)
(Contact Person) `---- (Phone) 9 - O 5 f
APPLICANT SIGNATURE ' DATE 9- L2 -io
APPLICANT PLEASE COMPLETE BELOW
Size of water service ,3/ inches.
Location of any coupling4f 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'l & Multi- family I% 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 $ Z 5. 5?)
STATE SURCHARGE $ .b — , 0 .53)
TOTAL PERMIT FEE $ - 3 C ..SO
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 30. Recei t No. & p
Dat B Q
Buildins Official Date / Q
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372