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3304 Alden Pond LaneUSEONt y PE F JT 6}26189, WA fi P RMff #iO SEWERPEt # B.P RE T # €; 1628 ik,,P RECEIPT C3ATE 4/.21 / 8 METER tZE ;DATE PRV � �_.:. BOOSTER PUMP r City of Evan 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Use BLUE or BLACK Ink For Office Use Permit #: Permit Fee: ..6. cx Date Received: Staff: 2012 SEWER AND WATER REPAIR / DISCONNECT PERMIT Date: 7 1(a City Sewer City Water f Repair Description Of Work: R ;,z Disconnect Fee: $60.00 Street Address for Proposed Work 3304, /11 P,4..) C3.4..7 j") (..4 OWNER Name: AZ-De/1J Ati ') eS Phone: 95-2 — CSr Address/City/Zip: 33')0 14 /O i AN -)43 Applicant is: Owner Contractor Name: Licensed Pipelayer X Master Plumber Property Owner .5e4J(,f4'' h ne: f/_ 26Z — 2.7 /8 gr'l /zr s7 Address / City / Zip: v� / 14...t ) Pipelayer Training Certification Card #: tOne).3.7 3or Master Plumber License #: I acknowledge that the information is complete and accurate and that the work will be in conformance with the ordinances and codes of the City of Eagan and the State of MN Statutes. I understand this is not a permit, but only an application for a permit, and work is not to start without a permit. Ly -z, Herr a Applicant (Print Name) Ap licant's Signature CALL BEFORE YOU DIG. Call Gopher State One CaII at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.gopherstateonecall.org