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�i PRIO Date Rec'd
CITY OF PRIOR LAKE `i , /- /3
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0 SEWER AND WATER PERMIT
M 'NNESO� A
2.
1. GrYellow een F1 City
PERMIT NO. y- e 12,24
3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
J .rd` I Cg F&UJ /bal TO. I N>-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
APPLICANT
(Name) t,-„ 4-100-1 4 4-'ru c,-)-;„ L L ( Phone ) 1 / -,- 3?-6-69y
(Address) 1 ? fo Ce A s) Z l0 g rti n ri 5-/3 }}
3---
(Address) / (City) (Zip Code)
(Contact Person) f c S +v- (Phone) 3 r o p y
APPLICANT SIGNATURE __ DATE _ // — / --/ 7
APPLICANT 11 PLEASE COMPLETE BELOW
Size of water service Nir 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.
FEE SCHEDULE
Residential sewer and water line connection $51.50 Industrial, Com'l & 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 ER AND WATER PERMIT FEE $ 2 £. Sy
"SURCHARGE" has been extended CE SURCHARGE $ 5, a
until June 30, 2013, AL PERMIT FEE $ 3 0. ,C0
The minimum surcharge for a
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid 30 , Rec it No. l®3.–Ce
Daty /�
Buildine Official Date I / - / 3 By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372