Untitled No 595
0
CITY OF FRIDLEY
PUBLIC WORKS DEPARTMENT
TAPPING APPLICATION AND PERAW
FOR INSTALLATION OF WATER&SEWER SERVICE
I) This form to be completed before a tap is made to any existing water or
sewer line.
Lot r2Q- Block ddition -
Address
Owner
Plumber '��� -�•
CHARGES TO BE PAID BEFORE TAP IS 4AA E — WHERE
ASSESSMENT HAS NOT BEEN LEVIED AGAINST PROPERTY
II) Water&sewer connection permit must be registered before this Tapping
Permit can be issued.
City supplies all material and labor for 1" or under water tap. Con-
tractor supplies all material and labor for water tap over 1", and all
sewertaps.
WATER TAP: 3`7,?o.V c 9. Materials Used: $
37a o. e L s Street Patch: '� x 9 $
TOTAL: $
SEWER TAP: 313°'® Street Patch: 5 x `� ; $ ��0 .0 C)
III) If this property has not paid a full Lateral Charge for its share of the
water and sewer system, additional charges will be placed against it.
This will be in addition to the normal connection and tapping permits,
meter deposits,etc.
Water
ASSESSMENTS TO BE LEVIED: Lateral: $
Sewer Lateral: $
TOTAL ASSESSMENT: $
Clerks Signature
Supt.of Public Works
M/P 3/76 White P.W. Canary Finance Pink Prop.Owner Goldenrod Plumber