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Date Rec'd
(4 :iIo4
.e CITY OF PRIOR LAKE
SEWER AND WATER PERMIT --'7kINNEso0
1. Green File
2. Geld PERMIT NO/5_ ii.,le3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
1 (J /gs Ln Ave E7.-
Lit
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) 4, 5 .l es 4, qs'� - vy7-zo3/
S (Phone)
(Address) 1 TS C.- y 47-2..-JS Ofiv 0 SL: 4 - s s 7e- -
(Address)/ (City) (Zip Code)
APPLICANT /2-- L Z - `�
(Name) Z A s �d (Phone)
(Address) /6 9 r /774. 54 A) AAV \ S S '3 7 2
(Address) (City) (Zip Code)
(Contact Person) ,A14,77-/ :4-1(-7 (Phone) `3 5-2 -WO,-/ 2 Q
APPLICANT SIGNATURE . -i !� A_- DATE 7-2-/ S
APPLICANT PLEASE COMPLETE BELOW
Size of water service --- inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC AnPVC El Cast Iron
Estimated length of sewer linea 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#
SEWER AND WATER PERMIT FEE $ /9.60 lne lvllnnesota statutes s SLnls.l'u
STATE SURCHARGE $ , A*• SURCHARGE has been extended
TOTAL PERMIT FEE $
The minimum surcharge for a
' "fixed fee"permit is$ OO
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt 1.1°, C16.--
Date
o ®1 _
Date 7-7 6 By / //t/
Building Official Date L -
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372