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Q vitro Date Rec'd
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V "` f SEWER AND WATER PERMIT 9: Z&. ii '" °ran F '` PERMIT NO. J 1
3 . V old A p p / / _
3. Oold Applicant
(Please type or print and sign at bottom
ADDRESS f ZONING (office use) ar_
17 ) '5 asA - 61)e-ack) LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OER i G� / 2 p �
(Name) ,Par l. I II _' 1 (Phone) .J( - 4 r /, ,- 3 0 0
(Address) I
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(Address) (City) (Zip Code)
Name )0Z.-- CA COD ) i - „`v i (N ) � � � htne
(Address) i - 1 A I an - - rim ' -
(Address) (City) q (Zip Code)
(Contact Person) )1v (Phone) 0,R - V l -7 - )
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Size of water service inches.
Location of any couplings from structure feet.
Type of sewer pipe. ❑ ABC 0 PVC ❑ Cast Iron
Estimated length of sewer line feet.
Clean out (if required) located at feet from structure.
TEE 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 140 Water connection only $25.50
. Estimated Cost $ Building Permit #
SEWER AND WATER PERMIT FEE $ S . S 0
STATE SURCHARGE $ 5 n
TOTAL PERMIT FEE $ a • S
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 3 5U Rec p o. / J T'
Building Official Date Dateg Z / / By UJ
24 hour notice for all inspections (952) 447 - 9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372