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CITY OF PRIOR LAKE -1. �' bg
SEWER AND WATER PERMIT
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1. Green File I PERMIT NO.OS,het
_--A_,Yellow City
3. Gold Applicant
(Please type or print and sign at bottom) ZONING(ofE ce use)
ADDRESS
4f3S4 Pbeeio 6CA— tT,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
PID
OWNS j D1-� (Phone) ��-dA
(Name)°� v` .
(Address) N3E-` X C-1-1 '51 ' ,., i (Zip Code)
(Address)
APPLICANT,•• t \ (Phone) 61.)--ask, -(0&78a—,
(Name) �c�--a.
(Address) -5853 1V ` ta 'Si'iiii
(City) (Zip Code)
DATE �
(Address)
(Contact Person) (Phone)
` SJ �
APPLICANT SIGNAT ' • �
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC 0 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'!&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 $ 25 ,S0
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 26 .(lb
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid . D O Re eipt No.5, 2
III
Building Official Date Date.7 i.off V •
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372