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SCOTT COUNTY, MINNESOTA Permit# 38537
INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PUMPING PERMIT
Owner 6c-. t A- 0, O 0 5.7 --1 Address ) i '76' l)./c / 3j7
Pumper J /6 '- ' s5 No. of Tanks Pumped ) Total Gallons Pumped /6 C (—'
Check all that apply: 'Residential ❑ Commercial ❑Rental
Septic ❑ Holding ❑ Pump Chamber ❑ Cesspool n Abandoned ❑ Other:
Condition of Baffles (baffles must be inspected) Acceptable 111 Unacceptable ❑Replaced Baffles
Depth of sludge layer 4 inches
Disposal Location (be specific) 44 ()---
Did you observe a surface discharge? ❑ Yes '[ No
Pumped From: ❑ Maintenance Hole E emoved Tank Lid(stave, for example) ❑ Inspection Pipe(see below)
I have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely
if the tank is not pumped through the Maintenance Hole/Tank Lid to enable the removal of solids.
Signature of Owner/Owner's Agent Reason fornotpumping through the Maintenance Hole/Tank Lid
Comments )jo ()(CtP 0 1 C ��
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Pumper/Inspector Signature ., S. ----- Date )0 +1C3
Only one permit is needed per ISTS.If there is ore than one ISIS on a property, submit a separate permit for each ISTS.
Submit a permit whenever a tank is pumped fo abandonment. Pumping the tank does not constitute a compliance inspection.
White-County Canary-Homeowner Pink-Pumper Form#1120
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MAPLE LANE, MUSHTOWN RD, PANAMA AVE
WATER & SEWER CONNECTIONS
PROPERTY
Property Address: 17056 MAPLE LN SE PID: 254200100
Property Owner Name: GUDERJAN GERALD A&HILDA M Phone 1: (952)447-5420
Property Owner Address: 17056 MAPLE LN SE PRIOR LAKE MN 55372
Owner Email: MUSKIE41@GMAIL.COM Phone 2: :
PERMIT/CONTRACTORS
Building Utility/Connection Permit#: 15-1176 Date Issued: 12:00:00 AM
Sewer Contractor Name: DeRudder Exc. Date Issued: 12:00:00 AM Phone: (612)919-4129
Plumber Contractor Name: Gerald Guderjan Date Issued:12:00:00 AM Phone: (952)447-5420
INSPECTIONS
DATE OF CONNECTION DEADLINE: 9/26/2016
Sewer/Water Install Completed: Yes Date: 12:00:00 AM
Plumbing Rough-In Completed: Yes Date: 10-20-15
Water Meter Install Completed: Yes Date: 12:00:00 AM
Plumbing Final Completed: Yes Date: 11-1-15
Septic Pump Ticket Received: Yes Date: 10-1-15
Septic Removed/Crushed Completed: Yes Date: 10-1-15
Well Capped Completed: Keeping Well Date: NOT REQUIRED
Asbuilt/Ties Completed: Yes Date: 12:00:00 AM
Grading Completed: Yes Date: 11-1-15
Final Inspection Completed: Yes Date: 11-1-15
PLEASE DO THE FOLLOWING OUTSTANDING ITEMS NEEDED FOR COMPLETION:
1.Bed Sewer 2.Insulate Lines 3.Curb Box @ Grade 4.Repair Tracer Wire
5.Box Cover Missing 6.Erosion Control 7.Clean Street 8.Grade
9.Water Hookup 10.Sewer Hookup 11.MXU Hookup 12.Seal Meter
13.Pump Ticket 14.Crush/Fill Septic 15.Remove Sewer Mound 16.Seal Well
17.Seed/Sod 18.Asbuilt/Ties 19.Repair Cut Line 20.Repair Driveway
21.Repair Floor 22.Install Flr Drain
COMMENTS:
DEFAULT STATUS
Property in Default: NO 1-Year Letter Sent: NO
Default Date: 9/26/2016 Date Default Letter Sent: N/A
Additional Default Action Taken:
UTILITY CONNECTION FOR THIS PROPERTY IS: CLOSED
J:\UTILITY CONNECTIONS\Maple, Mushtown, Panama Utility Connection\MAPLE LANE117056 MAPLE LANE.docxNovember 12,2015
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MAPLE LANE, MUSHTOWN RD, PANAMA AVE
WATER & SEWER CONNECTIONS
PROPERTY
Property Address: 17056 MAPLE LN SE
Property Owner Name: GUDERJAN GERALD A&HILDA M PID: 254200100
Property Owner Address: 17056 MAPLE LN SE PRIOR LAKE MN 55372 Phone 1: (952)447-5420
Owner Email: MUSKIE41@GMAIL.COM
Phone 2: :
PERMIT/CONTRACTORS
Building Utility/Connection Permit#: 15-1176
Date Issued: 9/29/15
Sewer Contractor Name: DeRudder Exc.
Date Issued: 9/29/15 Phone: (612)919-4129
Plumber Contractor Name: Gerald Guderjan Date Issued:9/29/15
Phone: (952)447-5420
INSPECTIONS
DATE OF CONNECTION DEADLINE: 9/26/2016
Sewer/Water Install Completed: Yes
Plumbing Rough-In Completed: No Date: 10-1-15
Water Meter Install Completed: No Date:
Plumbing Final Completed: Date:
Septic Pump Ticket Received: Yes
No Date:
Septic Removed/Crushed Completed: Yes Date: 10-1-15
Well Capped Completed: Date: 10-1-15
Asbuilt/Ties Completed: Yo Date: NOT REQUIRED
Yes Date: 10-1-15
Grading Completed: No
Final Inspection Completed: No Date:
Date:
PLEASE DO THE FOLLOWING OUTSTANDING ITEMS NEEDED FOR COMPLETION:
d
1.BeSewer X 2.Insulate Lines X
.BCover Missin 3.Curb Box @ Grade 4.Repair Tracer Wire X
g 6.Erosion Control X 7.Clean Street X 8.Grade X
9.Water Hookup 10.Sewer Hooku
13.Pum Ticket p 11.MXU Hookup X 12.Sea1 Meter X
p 14.Crush/Fill Septic 15.Remove Sewer Mound
17.Seed/Sod X 18.Asbuilt/Ties 16.Sea1 Well
21.Repair Floor X 19.Repair Cut Line 20.Repair Driveway
p 22.Install Fir Drain
COMMENTS:
DEFAULT STATUS
Property in Default: NO
Default Date: 1-Year Letter Sent: NO
9/26/2016 Date Default Letter Sent: N/A
Additional Default Action Taken:
UTILITY CONNECTION FOR THIS PROPERTY IS: OPEN
MJSH 1 OWN SEWER&WATER CONNECTIONS RECORD docx
ti MAPLE LANE, MUSHTOWN RD, PANAMA AVE
WATER & SEWER CONNECTIONS
Property Address: 17056 MAPLE LN SE PROPERTY
Property Owner Name: GUDERJAN GERALD A& HILDA M PID: 254200100
Property Owner Address: 17056 MAPLE LN SE PRIOR LAKE MN 55372 Phone 1: (952)447-5420
Owner Email: MUSKIE41@GMAIL.COM
Phone 2: :
PERMIT/CONTRACTORS
Building Utility/Connection Permit#: 15-1176
Date Issued: 9/29/15
Sewer Contractor Name: DeRudder Exc.
Date Issued: 9/29/15 Phone: (612)919-4129
Plumber Contractor Name: Gerald Guderjan Date Issued:9/29/15
Phone: (952)447-5420
INSPECTIONS
DATE OF CONNECTION DEADLINE: 9/26/2016
Sewer/Water Install Completed: A -Cs,
Plumbing Rough-In Completed: Date: la(1 (1-C
Water Meter Install Completed: Date:
Plumbing Final Completed: Date:
Septic Pump Ticket Received: y.es Date:
Septic Removed/Crushed Completed: es Date: ) ( 5—
= e, .�, - •d; ( Date:
We
Asbuilt/Ties Completed: \I e5 Date: NONE
Grading Completed: Date: 1 b t f
Final Inspection Completed: Date:
Date:
PLEASE DO II .FOLLOWING OUTSTAN I ING ITEMS NEEDED FOR COMPLETION:
1.Bed Sewer Zi 2.Insulate Lines W.
5.Box Cover Missin 0 3.Curb Box @ G ade 0 4.Repair Tjacer Wire
g6.Erosion Control /2 7.Clean Street .
9.Water Hookup 0 10.Sewer Hooku ❑ $.Grade
13.Pump Tick t ❑ 14.0p 11.MXU Hookup�. 12.Seal Meter
rush/Fill Septic 0 15.Remove Sewer Mound 0 16.Seal Well 0
17.Seed/Sod 18.Asbuilt/Ties 0
19.Repair Cut Line 0 20.Repair Driveway ❑
21.Repair Floor 22.Install Fir Drain 0
COMMENTS:
DEFAULT STATUS
Property in Default: NO
Default Date: 9/26/2016 1-Year Letter Sent: NO
Additional Default Action Taken: Date Default Letter Sent: N/A
UTILITY CONNECTION FOR THIS PROPERTY IS: OPEN
U I ILICONNECT IONS\Miaple tvushtown Panama Utility Conne ;..
MAPLE LANE, MUSHTOWN RD, PANAMA AVE
WATER & SEWER CONNECTIONS
Property Address: 17056 MAPLE LN SE PROPERTY
Property Owner Name: GUDERJAN GERALD A& HILDA M PID: 254200100
Property Owner Address: 17056 MAPLE LN SE PRIOR LAKE MN 55372 Phone 1: (952)447-5420
Owner Email: MUSKIE41@GMAIL.COM
Phone 2: :
PERMIT/CONTRACTORS
Building Utility/Connection Permit#: 15-1176
Date Issued: 9/29/15
Sewer Contractor Name: DeRudder Exc.
Date Issued: 9/29/15 Phone: (612)919-4129
Plumber Contractor Name: Gerald Guderjan Date Issued:9/29/15
Phone: (952)447-5420
INSPECTIONS
DATE OF CONNECTION DEADLINE: 9/26/2016
Sewer/Water Install Completed:
Plumbing Rough-In Completed: Date:
Water Meter Install Completed: Date:
Plumbing Final Completed: Date:
Septic Pump Ticket Received: Date:
Septic Removed/Crushed Completed: Date:
Well Capped Completed: N/A Date:
Asbuilt/Ties Completed: Date: NONE
Grading Completed: Date:
Final Inspection Completed: Date:
Date:
PLEASE DO THE FOLLOWING OUTSTANDING ITEMS NEEDED FOR COMPLETION:
d
1.BeSewer 0 2.Insulate Lines 0.BCover Missin 0 3.Curb Box @ Grade 0 4.Repair Tracer Wire 0
5g6.Erosion Control 0 7.Clean Street 0
9.Water Hookup 0 10.Sewer Hookup0 8.Grade 0
13.Pump Ticket 0 1LMXU Hookup 0 12.Sea1 Meter 0
14.Crush/Fill Septic 0 15.Remove Sewer Mound 0 16.Seal Well 0
17.Seed/Sod 0 18.Asbuilt/Ties 0
21.Repair Floor 0 19.Repair Cut Line 0 20.Repair Driveway 0
22.Install Fir Drain 0
COMMENTS:
DEFAULT STATUS
Property in Default: NO
Default Date: 9/26/2016 1-Year Letter Sent: NO
Additional Default Action Taken: Date Default Letter Sent: N/A
UTILITY CONNECTION FOR THIS PROPERTY IS: OPEN
i�d i C;UPJiNEc i IONSitviaple Mushtown Panama Utility Connection\MAI (,,
of PR/04, CITY OF PRIOR LAKE BUILDING PERMIT,
A. t. TEMPORARY CERTIFICATE OF ZONING COMPLIANCE Date Recd
v
AND UTILITY CONNECTION PERMIT
.......)
2iwhiPink te FiCilety 4 I PERMIT NO. L -� 1J
5 �/
(Please type or print and sign at bottom) Yellow Applicant
ADDRESS `
ZONING(office use)
/70�, SPAU lA.�� s. La. fgz ,44/(6,14,)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
PID
OWNER �/ n !,(U�
(Name) F RA I L // 0/4 Gil D . IQ34 AJ (Phone) ?'S—G2 " / 7/- 5 51-2 0
(Address)/70S(p 4/4,cg /I S 0..) pg Xe k //4/ ) Mu SS 37 Z
BUILDER ���
(Company Name) NIu !c -.7t (!A M.7'•Z•V q (Phone) 96-62 4/4/7~ r
(Contact Name) Zi£r, A iL4 I?(.4 JJ Eric. (Phone) 4/ Z - giq_ iia ?
Phone
(Address) V. 0:0 ZcK6Ky / Ill S 7X( I / i Z0re LAR si I S 3 ?
TYPE OF WORK O New Construction ODeck ❑Porch
ORe-Roofing ❑Re-Siding OLower Level Finish ❑Fireplace
DAddition DAlteration Altility Connection
CODE: ❑I.R.C. ❑I.B.C.
0 Misc.
Type of Construction: I II III IV V A B
Occupancy Group: A B E F H I M R S U PROJECT COST/VALUE $
Division: 1 2 3 4 5 (excluding land)
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the
above-mentioned property and thatonstruction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
Iofficial c,u evoke tit formf ause utthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
X ./ ; '/' / /
y- 1_5 , 15-
Igna
Contractor's License No. Date
Permit Valuation Park Support Fee #
Permit Fee $
$ SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; 2.95 --,State Surcharge $ $ ���.a)
Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # '
Plumbing Permit Fee $
,50 Water Tower Fee # $ /tJC, 0_a)
Mechanical Permit Fee $
Builder's Deposit $
Sewer&Water Permit Fee $ 5 L ) Other
Gas Fireplace Permit Fee a $
$ TOTAL DUE
This Application Becomes Your Building Permit When ApprovedPaid .57 � 7
i i
� Recei.t No. 7
Date '''' 2...-- ! ' BI1/_'
Building Official Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy,a Certificate of Occupancy must be
issued
Planning Director Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 Special Conditions,if any
4646 Dakota Street Prior Lake,MN 55372
/aJ/eii Jof%or%or lc/Ke,, �7ni
r Rl
� � Date Recd
CITY OF PRIOR LAKE
*5�;F; � SEWER AND WATER PERMIT
4I1'NESO
I Yellow city PERMIT NO. /5, r („
3. Gold Applicant //710/7
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/7v1/4S- m 't11' lA 6 .Sri, Axt111/04 Mil
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER [i _
(Name) G'fiK/4LI0 °M a t'14 (7L .2 E11,T/bi-'
(Address)fib St it A.,,e.._ ,c,i0 . P zit) p- 14k( Pit/ ,-377 2_
(Address) (Cit
(Zip Code)
APPLIC q
(Name) /c tvdc/' ( r C(1.4 VA T% 7 (Phone) 9S-2- /t/9 7- I/ 2/
(Address) 'V /t /fce//'t'y ��LI.S X. 47.7-or iifrie h�,t,e� - -,s--,31 2-
( d (City)rese1
''� 1 I (Zip Code)
ontact Person) 'i/ t AV"„j Alp
Ank (Phone) .y.5--1 c- V97- P-1 z/
AXCPPLICANT SIGNATURE .Airra� DATE /��S
APPLICANT PLEASE COMPLETE BELOW
Size of 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%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 $ The Minnesota Statutes§3266.148
STATE SURCHARGE $ "SURCHARGE"has been extended
TOTAL PERMIT FEE $ The minimum surcharge for a
"fixed fee"permit is$5.00
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date p to 1
Buildine Official Date
U 1 I �/�1
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 P�,n t,---'
PRICITY OF PRIORDate Rec'd
�, LAKE PLUMBING PERMIT 9 m. (S...--
0.
Esoo
0o
I. Blue File I PERMIT NO/5
(Please type or print and sign at bottom) 2. cold city 117,E I
3. Yellow Applicant
ADDRESS
f 7O� M/'niC �_, j�E ��„� n ZONING(office use)
`� �( t r .Z.01 405, fl
AJ
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
PID
OWNER A lf
(Name) 1ge,4/ 0 121— Jt�Z L b A C 4 b rt<,7i¢,.1 9`S.2-- yW. -S—Y2 U
,Q,� (Phone)
(Address) �70 5'7 ��;.�.'I t I/ A4 J ) 144 T.0 i'L
IAK5., 4.v' S 513 l'Z_
APPLICANT
(Name) g Pzle:�-l.I� c._L 1.2
96
(Phone) 17/1/7., S ya
(Address) $/ /1 6 d t4
(Address)
�+ (City) (Zip Code)
(Contact Person) C� a/<'f.) Ci4 i 0; nAi
If/ (Phone) 9 .? 9/y 7 .5-31.2 CJ
APPLICANT SIGNATURE ,i ,/_ 4 9'/-7:2-0/S—`
�,
DATE /- o2-0/.S`
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture
Bath Tub with or without shower QuantityType of Fixture
Dishwasher Rough-ins
Floor Drain Water Heater
Lavatory(Bathroom Sink) Water Softener
Laundry Tray(1 or 2 compartment sink Stand Pipe(Washing Machine)
Shower Stall Sewage Ejector
Sinks Backflow Assembly
Bar Sink Backflow Assembly Test
Water Closet(Toilet) Lawn Sprinkler
Other
FEE Industrial,Commercial&Multi-family 1%of job cost with$49.50 ULE
minimum
Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The Minnesota Statutes§326B.143 $
"SURCHARGE"has been extended Building Permit# ` `/
The minimum surcharge for a PLUMBING PERMIT FEE $ l� ' 1 I
"fixed fee"permit is$5.00 STATE SURCHARGE $ _ .50 _00,1d
TOTAL PERMIT FEE $ eo
CA�
This Application Becomes Your Building Permit When Approved Paid
\S(
Receipt No.
Buildine Official
Date Date By
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372