Permits - Permit# 03-02 - 2401 Black Lake Road - 1/1/2003Account No.
Village of
Spring Park,
Minnesota
APPLICATION FOR PERMIT
Property Owner
Name r)�CzGI0,1 AJOq
Address `21yo/ Bach oeatce ie
Telephone
For Connectpn To:
Water r/
Sewer
Permit No.
PERMIJ FEES
Water _ 'AS
Sewer 1_;1 -.5—
Meter Deposit
Total
Name ��
Contractor
� L
Address
Hnzred
Telephone.
6t2—r&j .(o/Lb
Permit No.
Expires:
To Be filled out for Both Sewer or Water
Legal Description of Property Plot Lot Parcel Block Add.
Has Assessment been levied? Yes No
No. of Building or unit to be served. Water Sewer
Type of Building: Res. Comm'I. Indus. Other
Are Water and Sewer to be installed in same trench? Yes No
Is there Basement Under Bldg? Yes No Full Partial
Water I I Sewer
Use of Water. General
Approx. Mo. per year to be used _
Size of Service Required:.
Point of Entry to Bldg.
Meter Location
Special
The Undersigned hereby agrees:
To notify the Inspector when work is ready for
inspection, and not cover any work until such
inspection is made and the work approved.
Contractor —Al
APPROVED BY
Rem ark s:
Are all buildings properly vented
Service Pipe: V. Clay Cast Iron
Size - Length
Point of Entry to Bldg.
Kind of Joint Used
Is Pretreatment Required? Yes
AFFIDAVIT
No
By signing this application, I do hereby declare that
all Statements herein contained, are true and correct.
That all work for which this application is made will
be performed in accordance with applicable Ordinance
of the Village of Spring Park, the State of Minnesota,
and the rulings of the Public Utilities Department.
If at the time this application is made, the Special
Assessments have not been levied, I do further con-
sent to the spreading of the pro-rata assessment
against the described property.
Date
Owner
FORM SW 1