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~ +865 City of Lakeville J,~®
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INSPECTION DEPARTMENT
SEWER AND WATER PERMIT Permit Fee.......... ~~-SQ
AND RECEIPT stalte surthat?ge
TOTA1. FED PAID . 40, bQ
Permission is h*nby yronted to JerChe Excavntanlq/Co~.l~e City, Cons~,r
Suiidin~ on Lot Nm R Btock Subdivis+on Aodd.-~:OiA~,e
Parcel ~~22-20860-0$0-01 Plat
E i,
in the CITY OF LAKEVILLE o be used as
This permit is issued on the express condition that the -.ERECTION ____ALTERATtON ._.._REPAfRS
INSI`AI.LMENT ._._MOViNG ____.DEMOLITIONr~spects to the statements certified to in the applitstiott for
sach prot~mit~ and fhat ail work shall be done in accordance with the Ordinance of LAKEVILLE, Minnesota antti the State
oi'' Minnesota pertaintro to tfie construction of buildings.
Street Address` ~ 16131 Eic .e1 s or D iva Gl~~,t~ A Langctrd
AttdMNfpn b t t:eNed lb ste Wnino up tff sheets, making main sewer connections, driveways and DirettOr, t.ICMi! eea Ins~ttfOrt ;
-CUbB:. tabteh 6e~ttfor 6UCh caheNtxt(gn'tranthe CITY OF LAKEVILLE. Inspection Oepartmenl Not
PfesponsY5la For Any Damages to Pt~IbNC UtNlties.
lit9 pew hotd9r tlAdlr~ttf~ god apleg8 th9t greeting this permit is not a warranty or representation by
iM tSly 1 q~ D?Mect wNl be safe oraetls/ectory. B
Y
The psnnl( holder understands and agrees [hat the Cify shall have the right to make periodic inspection ~ -
dutny fl the petmfl holder duos not make arrangement for the nspection the City may tun
off the water utdl such inspection has been made.
c~ , ~ CITY OF LAKEVILLE
,SEWER AND WATER PERMIT APPLICATION
~ Date C~
~t~
Job Site Address / ] i
Legal: Lot Bloc (k Addition
Owner or Builder I ( G ` C.. ~ i~t
Excavating Contractor ~ ~ ~ ~ Tel.~~/ L ~J
Address l ( w ~ G ~ VL U I "L ~ e City ~ Zip ~ r
r_
Private Sewer System ($39.50 + .SO) $
Private Sewer Repair ($19.50 + .50) $
City Sewer & Water Connections*(39.50 + .50). $
Inside Plumbing Conversion (19.50 + .50)• • $
Sewer Connection Only ($19.50 + .50). $ 1%~,Q ~
Water Connection Only ($19..50 + ,50). - $ ri~~i t a
Meter-($60.00) &-Pressure Reducing Valte. • $
* Metro SAC Charge S/W Connection Units • $
TOTAL CHARGES $ r Q
Ts Street Excavation necessary? Yes
No V
rr~ ~
IF
Signed G~
Make checks payable to: City of Lakeville
Send payment to: City of Lakeville Glenn A. .(Barney) Langord
Inspection Dept. Plumbing & Heating Inspect.
Box 457
Lakeville, MN 55044 Tel: (612) 469-4431