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o � PRIO� Date Rec'd
� � CITY OF PRIOR LAKE /
� r� SEWER AND WATER PERMIT �� `�` � Z '
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`. �e� F;`` pERMIT NO.
2. Yellow City
� 3. Gold Applicant ./
lease or ' t and si at bottom
ADDRESS ZONING (ot�ce use)
/�S' r s�
LEGAL DESCRiPTION (ofleice use only)
LOT BLOCK ADDITION PID
(Na�ine) �,[� !/ � �r ��S/�jgi✓ (Phone)
(Address) s�.Sy /�J��/�G� .l'T .S� ` ,�/0/r ,� �'/'' 11?7 Z
(Address) (City) (Zip Code)
APPLIC T
(Name) a j�� D D 7 �� (Phone)
(Address) �Y.f � ��f ,/�' /�'. ���'� OdiiJ' �- s'f 5�Y7
(Address) � (City) (Zip Code)
(Contact Person) «i� " (Phone) �t � ' 2�G • �.2 g' �
APPLICANT SIGNATURE � " DATE ���1'' 2 U
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
' se Sf�n�-�a ter 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
v �'
Estimated Cost �90D Building Permit #
The Minnesota Statutes § 326B148 ;R AND WATER PERMIT FEE $ Z.�. S�
"SURCHARGE" has been extended E SURCHARGE $ S_ GK�
until june 30, 2013, �L PERMIT FEE $ .� �.��
The minimum surcharge for a
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid .4�� , S � Re i No./ � y�
J ��
Date
Buildin¢ Official Date �• � �� /� �
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372