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INSPECTION DEPARTMENT
SEWER AND WATER PERMIT Permit Fee.......... s9.so
AND RECEIPT State Surcharge 'S~
TOTAL FEE PAID . OC)
` N3ltnwr P7 tmb•tTt .Toe Miller F.nnct•r
P~rmissioar is tter.by granted to gt -
Builditlq ota Lot "No. 1 A 131ock 1~ Subdivision ~nnnu~! ~ V a3+ Park Sth Addis
P~reei~22-21177-100-12 Plat
in the GITYOF LAKEViL6E to be used as Permit to connect to city water and sewer ffiystetn
This permit is issued on the express eondition that the ____EREC710N _e__.ALTERATtON.REPAIRS
INSTALLMENT ~MOViNG -DEMOLITION respects to the statements certified to in the sppiicafion for
i suth permit, and that all work shall'be done in accordance with the Ordinance of LAKEYILLE, Minnesata and the State
of Minnesota `pertaining to the construction of buildings.
Street Address 16180 sai o•r .ten AVPnIIP _,~j,~,ann A ,j,gna~rl
AtteMltlen N p9Akularty Celled to the cutNrtq Up of anaets:making main sewer connection, driveways and Director, Licanee iod InttpecHOn
Cilbe.:OtfteYl permit for each conetruciionkom the GTY OF LAKEVtLLE. Inspection Department Not
ReepOmible FaArry DpmeOes to Pubbc tJ 6Nties. ,
- The penhlFhOWer ulltlerS1911dE end agrees that granting this permit is not a warrarNy or representation by
the GtY the the project vWll hit safe or satisfactory. B
Y
The permithgWer UlWerelBlWe and agrees that the City shat! have foe right to make periodic inspection
dtrNp slat: M; the pennN holder does not make arrangement for the inspection the City may tam
ofF the weMr 1NItaIBUCh I~ep9cfton has baen made.
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CITY OF LAKEVILLE
,SEWER AND WATER PERMIT APPLICATION
Date C~'/~~ 0 .
Job Site Address ~%'y~'Y't'~1~.
u'
Legal: Lot Block Addition
Owner or Builder ~(/~Q
Excavating Contractor i ~K T .~a~~~Q~
Address l ~7 ,~~~C~ ~ C,-''~. City i~~~1° , Zip
Private Sewer System ($39.50 + .50) $
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). $
Water Connection Only ($19.50 + .50). - $
Meter-($60.00) &-Pressure Reducing Valve. . $
* Metro SAC Charge S/W Connection Units $
TOTAL CHARGES $ ~O•
Is Street Excavation necessary? Yes
No !
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Signed .c~L ,
Make checks payable to: City of Lakeville
Send payment to: City of Lakeville Glenn A. .(Barney) Langord
Inspection Dept. Plumbing & Heating Inspect.
Box g57
Lakeville, MN 55044 Tel: (612) 469-4431