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4585 Lake Park Dr - I&I96698RESIDENT / OWNER Name: - .....1 ?-,--.s Phone: 6Z 1 c-St - 31 VA Address / City / Zip: .....^-- , CONTRACTOR Name: \,� �..sti- c- -�-c ' ' . k..---- \- \ License #: - 9 \ t 4 . ° 3 4 Address: l 6 6 A. C•o --►eg `-cv -\ City: / State: 1.--CP.--) Zip: S'S ( 3 Phone: cow` `! 3 r 3 D--3 Contact: - Email: c t A c___ ,c-- s-\ . 1 TYPE OF WORK PLUM ING (Within the building envelope) SEWER & WATER (Outside the building envelope) , Sump Pump Repair Repair Other: Other: DESCRIPTION Description of work: -�-- c \: �...� FEES $55.00 / Each (includes $5.00 State Surcharge) TOTAL FEE $ �� City atEaQan Date: `©/ / t � Site Address: Tenant: 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675 -5675 Fax: (651) 675 -5694 r L Permit #: ` ( 6 6 8 Permit Fee: 55 . OD Date Received: \O /2-81 0 Staff: t'7 U INFLOW & INFILTRATION PERMIT APPLICATION Plumbing / Sewer & Water L,t �.�� e.. �•--� J'C"`_ � Vim.. Use BLUE or BLACK Ink Suite #: *Permit fees will NOT be reimbursed by the City of Eagan. If you plan to submit I/1 repair costs for reimbursement, two quotes from qualified contractors must accompany this application. A list of contractors can be found by visiting www.citvofeagan.com /inflow, or City Hall at 3830 Pilot Knob Rd. CALL BEFORE YOU DIG. Call Gopher State One Call 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.gooherstateonecall.orq I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an , cation for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of wor ich requires a review and approval of plans. Applicant's Printed Name x Applicant's Signat i re