HomeMy WebLinkAbout1987-07-28 Permit, Water Well #9144f*":
GENERAL PERMH
OTYOFORONO
P.O.BOX66
CRYSTAL BAY, MINNESOTA 55323
(612)473-7357
Owner A'O—^^’'CLSJI
CITY PERMIT N? 9144
Dale 7-^y ______
City License No. ------------j Lf ^----------------------
Address tr^AjO 2)^-
City
Address
REMARKS AND SPECIAL CONDITIONS
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PERMIT TYPE AND FEE)
Inside Plumbiitg (Kfixiuies —-)
^NEW
Fee $
□ REPAIR
Wiler Meter (Size
Meter#___
.)Fee S
Remote#
Munidpii >Miter Connection
□ Copper □ ------
Fee S
i
Municipal Sewer (Connection
□ PVC O Cast □
MWCC SAC Charge
On Site Spetic System
Fee $
□ ADDITION
Witer Well
Mechanical Equipment
Fiieplace/Wood Stove
Moving/Lifting Buildings
Land Alteration (Excavation,
Grading, Filling, etc.)
Design Review
Fire-------------------------
Fee S
Fee $
□ REMODEL
Fee S ,3^:0^
Fee $
Fm S
Fee $
Sprinkler System (Fire)
Other. -----------------
After-the-fact Investigation
Fee S
Fee $
Fee $
Fee $
Fee $
Fee $m
m
ACKNOWLEDGEMENT
Thr unJerogncd hereby acl(nowln%es mxipi of this limited pennit.
indudinf atxrriana- (if all special infonnalion. lerrm. condiiiom iv
rei)uireincnl5 wrilien abovf. The underttfmed undet^nds and agrees
under penally of law that this permit is stnctJy limited in vope to the wnrk.
actisily ur impnnemeni specified: that this permit dues nut grant any
authority to do work or activities requiring separate permit approvab; and
that this permit does not grant authority to violaie any provision of any City
ordinance or Stale law. rule or regulation. All work shall be done in strict
cwnpliance with ah City ordinances, building aides and/or health
department regulations, and shall b' si*^ ui inspection, approval or
rejankw by the City. Whenever so ordered, the undersigned agrees to
correct any work found to be in violation of the conditions of this permit.
TOTAL
State Surcharge:Fee $,sz)
Total Amount Riid to City Fee
This permit is not valid until the proper fee is paid and it is approved
by an autk r'^jcd City Official.
.s
Signature of Applicant Signature of City Official: iji K^iiy v^iiicHu^ (JA
Codr White—RIc Copy Canary--Inspector's Copy Pink—Rnance Copy Gold- Applicant’s Receipt