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pBio�P Date Rec'd
CITY OF PRIOR LAKE
t rx SEWER AND WATER PERMIT L( - 1 ( C
"NwEsOlP
Green File I PERMIT NO.
03 1
3. Gold App /� l
3. Gold Applicant (/
(Please type or print and sign at bottom) aP
ADDRESS
ZONING(offic use)
1143 so leers 80
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name)
(Phone)
(Address)
(Address)
(City) (Zip Code)
APPLICANT
(Name) S C Iv e/ -/ p ( I ; A ( (Phone) a S Z" 4l4#7— ei 7 3 af
(Address) l s c 46 g G2. ap../e r /Z c p z,/'--C /'� 5-5-5-1 z_
(Address) (City)
e- -C- C'- :"I C/ (Zip Code)
(Contact Person) (Phone) £P( Z— Cf 7— 30 v 3
APPLICANT SIGNATURE --C 1-/i r. - DATE //` 5--�- /0
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet. W`�} s�v'ce `�--
Type of sewer pipe. 0 ABC E PVC El 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 $35.50 Industrial, Com'l&Multi-family 1%of job cost with a$39.50 minimum
Sewer connection only .50 Water connection only ...S-1-775(t—
Estimated Cost $ Building Permit#
SEWER AND WATER PERMIT FEE $ Z6-, Sa
STATE SURCHARGE $ 51 0 CO
TOTAL PERMIT FEE $ .3 00_,___-_ __
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid UrS V 0,pt No. /
Dat 0,Building Official Date I(_ I 0
24 hour notice for all inspections(952)447-9850,fax(952)447-4245