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Date Rec'd
A., � pR\t. CITY OF PRIOR LAKE
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\ , SEWER AND WATER PERMIT b' 131S
`. GreenFile
2. Yellow City PERMIT NO/5^ �/5
43. Gold Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
(g S 9 gilt Y Sr ,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER pekr Zeci 4e—'17' (Phone) 9 —9�'9 J— 6
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(Address) i U . ��wGf-
(Address) (City) (Zip Code)
APPLICANT �`
(Name) -1-AA.)0-- 0 1-C1 e.S cjZv},( L, v&A. Y t ik,(Phone) L a--3 (.Q CR-41
(Address) I1 as \ , 13S 4/k Sc-- . 5AVCOk S S 31
(Address) (City) (Zip Code)
(Contact Person) I Lia \:-1e SL k l (Phone) 110-a/.a-2a1 I %
APPLICANT SIGNATURE `-}� D DATE I -7---/5--
APPLICANT
/SAPPLICANT 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 75 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 $ )61`
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ 2(,. ,r'D
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid .WrO 219' Receipt No. -�
'� �'" By
0 Buildinn Official Date Date ' ("At 1
24 hour notice for all inspections(952)447-9850 6,d I Cho 111-/-
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
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