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NE DAYTON Office Use Only <br /> CITY SEWER AND WATER <br /> € YF. CONVERSION/CONNECTION Permit Number <br /> PERMIT APPLICATION <br /> CITY OF DAYTON Pennit Expiration <br /> 12260 S DIAMOND LAKE ROAD <br /> DAYTON,MN 55327 <br /> 763427-4589 Date Received <br /> SITE ADDRESS: <br /> CITY: STATE: ZIP: <br /> THE APPLICANT IS: ❑OWNER ❑CONTRACTOR JOB VALUATION: <br /> NAME <br /> RESIDENT OWNER ADDRESS <br /> CITY STATE ZIP <br /> DAYTIME PHONE#WHERE YOU CAN BE REACHED <br /> COMPANY NAME LICENSE# <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONTRACTOR CONTACT NAME__ <br /> DAYTIME PHONE#WHERE YOU CAN BE REACHED <br /> MASTER PLUMBER REQUIRED <br /> MASTER PLUMBER NAME: <br /> LICENSE# <br /> ❑SEWERIWATER CONVERSION <br /> PERMIT TYPE ❑SEWER CONNECT <br /> ❑WATER CONNECT <br /> CURRENT PERMIT FEES <br /> CONVERSION CONNECTION <br /> Sewer Permit/Surcharge $80.00 City Sewer Access Charge(SAC) $606.00 <br /> Water Permit/Surcharge $80.00 Metro Sewer Access Charge(SAC) $2,436.00 <br /> City Surcharge $7.60 Water Meter $326.64 <br /> TOTAL$167.50 Septic Tank Removal/Surcharge $0.00 <br /> TOTAL$3,366.64 <br /> TOTAL PERMIT COST$3,534.14 <br /> REQUIRED INSPECTIONS . <br /> CONVERSION CONNECTION <br /> ® Stubs and Capped End ® Double Shut Off and Final <br /> METER#: METER SIZE: METER MANUFACTURER: <br /> THE UNDERSIGNED HEREBY AGREES THAT,IN CASE SUCH PERMIT IS GRANTED,TIIAT ALL WORK WHICH SHALL BE DONE AND <br /> ALL MATERIALS WHICH SHALL BE USED SHALL COMPLY WITH THE PLANS AND SPECIFICATIONS HEREWITfi SUBMITTED AND <br /> WITH ALL THE ORDINANCES OF SAID CITY OF DAYTON APPLICABLE HERETO. <br /> Applicant's Signature Date <br />