HomeMy WebLinkAbout2017-00861 - sewer disconnect • � � � CITY OF ORONO * 2 0 1 7 - a 0 8 s 1 *
2750 KELLEY PARKWAY DATE ISSUED: 07/24/2017
ORONO,MN 55356-
(952)249-4600 FAX: 952)249-4616
ADDRESS : 4105 HIGHWOOD RD
PIN : 07-117-23-44-0014
LEGAL DESC : HIGHWOOD LAKE MTKA
: LOT 016 BLOCK 000
PERMIT TYPE : SEWER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DISCONNECTION
NOTE: SEWER DISCONNECTION. �
APPLICANT SEWERCONNECT!DISCONNFC'T'RFP,�IR �n nn
STATE SURCHARGE SEWER&WATER 1.00
D.S.M. EXCAVATING TOTAL 51.00
2916 ENTERPRISE AVE
HASTINGS,MN 55033- Payment(s)
(651)480-1355 CREDIT CARD 5166 51.00
OWNER
PETERSON,JASON
4105 HIGHWOOD RD
MOLJND,MN 55364 .
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be perfortned according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. 7'his permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances goveming this rype of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked at any time for due cause.
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Applicant Permitee Signature / Date Issued B ignature Date
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� Cl'Y`Y�O]�L.Y
}�O�TO City of Orono Datie Rexi�ed: P«mii�t
P.O.Boa�66
2750 KeIkY p�Y O Ip-Fionsc�AC Dzte+minati�Form Compl�ed
� ,� Cryscal Bay,MN 55323
��t'�x�sHo�-``G` (952)249�600/Fa�c(952)249-4616 ApP�'��Y�RuN�:
CITY OF ORONO—SEWER&WATER/GENERAL PERMIT
(•Note:Some pumiu maY n9�aPP��aI by the Build'mg O�asl and/�Public Works Depa�ent•)
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GfiNE�Ai,INFORMATTOl� : .
1. You may apply far utility pernrits by maii or in person at the City offices.
2. Mailed in applications are subject to the postage and handling fee shown below. Peimit cards will
be sent by return mail within 2 business days.
3. Permits are not valid untit yon receive a permk card.
4. Work must not begin unless the permit card is available on the job site.
S. Utility connection permits may be issued to licensed cantractors only.
6. Contaact the Public Works Department(952-249-4600j for utility stub as-built locations.
DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN wit6out ezpress
approval of the PubHc Works Department. Issuance of a permit does not grant this approval.
7. All work must be done in accordance with State Code requirements.
8. All work must be inspected before it is covered. Call(952)249-4600,Z4+honr notice require�.
. T'YP��OF PER�IT �
Check�All That A:
�Residential(May Require Approval) ❑Commercial(Approval Required)
❑ New Connection ❑Additional Connection ❑Re-Connection ❑Repairs Disconnect
❑ Water Availability Connection For Fudue Hook-Up to Water
Ja� ��te/Ot��r L�o�afic�n:
Site Address: `��OS� f�/�:,NlvDb,j� �o�
Owner:_'T����Z- �'✓� Mailing Address: .
City: Zip:
Home Phone: Alternate Phone:
Contrac�or Tn�am�tion:
Contractor: , , - �� f
� �/N 1�C�Ri�i' � �NG. Contact Person: �/�E L���i,✓�
Address: 2 9/� S� �/�� State License#:
City: T19�'TN��S Zip: S�d� Expiration Date:
Phone: ��l y8�� 1�� Alternate Phone:
. � , .
D�'�'���:�TCi'�T FP�S
❑ SAC Charge(2015 Rate=52,485.00) �
(SAC Charge must accompany all sewer permit applications unless prepaid)
(Orono City Staff can determine if applicable)
(If not prepaid,a sewer connection permit will not be issued)
�]Sewer Connectio Disconn� Repair($50.00/Per Stuti) $
Pipe size inches;material Schd 40 air tested; cast iron
❑Water Connection/Disconnect/Repair($50.00/Per Stub) $
Pipe size inches;material Schd 40 air tested; copPer
❑Water Availability For Future Hook Up to Water(550.00) $
Water Availabilitv Eznlanatlon:
Contractor installed line to inside of house for fiihue hook-up.
This line will be inspected by the Public Works Department. �
Requ�',red�^fore Water Connection Permit is Issued:
1. Issue Water Meter&Horn Permit
2. Any Additional Connection Fees Paid(If Applicable)
T�sue Water Connection Permit:
1. Collect Permit Fee&Issue Water Connection Permit
1. SUBTOTAL of Permit Requested: �
2. STATE SURCHARGE $ 1.00
3. POSTAGE&HANDLING(On]y on Mail-In Applications) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $
ADDITIONAL INFORMATION-V�ATER METERS
• WATER METERS must be picked up and paid for at Orono City Hall,these are on a seuarate permit.
■ WATER METERS must be set and sealed by Orono Water Department (952) 249-4600, upon
completion of ineter installation.
The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do
all work in strict accordance with the ordinances of the City and the regulations of the State of .
Minnesota,and certifies that all statements made on this application are,true and correct.
Applicant: Date: ��y��
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