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71;Y:PRIORLAKESEWATER PERMIT
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2. Yellow 1. Green Filey PERMIT NO. 12 i44
3. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
3715 Island View)4d CLC
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) Forest Graser (Phone) _612-716-4431
(Address) _3715 Island View Road _Prior Lake 55372
(Address) (City) (Zip Code)
APPLICANT
(Name)_Krueger Excavating Inc (Phone) _952-447-8835
(Address) _P.O.Box 729 Prior Lake MN 55372
(Address) (City) (Zip Code)
(Contact Person) Nate (Phone) 952-292-0154
APPLICANT SIGNATURE C
DATE _7-27-2012
APPLICANT PLEASE COMPLETE BELOW
Size of water service 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'1&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 $ 6-,co
STATE SURCHARGE $ Sp p
TOTAL PERMIT FEE $ 30 ccs
(Office Use Only)
This Applic. io Becomes Your Building P rmit hen Approved Paid Receipt No.
�'1 ii 30. so 44 5-70
'� � c Date
Bu' %r a Date /uQ��` By fifrja__
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372