SURVEYING YESTERDAY, TODAY, FOR TOMORROW
An Equal Opportunity Employer
SAINT LOUIS COUNTY
PUBLIC LAND SURVEY MONUMENTATION
REIMBURSEMENT APPLICATION FORM
Payable To:___________________________________________________________________
Address:______________________________________________________________________
SLC Vendor No.:_____________ (if known)
Reimbursement requested for the following Corner(s):_______________________________
______________________________________________________________________________
______________________________________________________________________________
In conjunction with a private land survey performed for:_____________________________
______________________________________________________________________________
I hereby state that I am an independent contractor and am not an employee or agent of Saint Louis
County. I agree to protect, indemnify, and hold harmless Saint Louis County from any and all
causes of action, claims, demands, suits, liability or expense by reason of loss or damage to any
property, or bodily injury to any person as a direct or indirect result of my operations or in
connection with any action or omission of mine or those employed by me. I further understand and
agree that acceptance of a Land Corner Record or that payment for same under this program shall
not imply that Saint Louis County places any sanction on the corner position, and that the liability
for the authenticity, accuracy, and acceptability of the corner position lies entirely with the
contractor.
Surveyor's Signature ______________________________________ Date ________________
Printed Name ______________________________________ Mn. Lic. No.________________
Please return completed application form, corner certificates, and a signed copy of the related
certificate of survey to the Saint Louis County Surveyor's Office.
Initial Number of Corners Submitted _______ ($650/corner ) Preliminary Amount __________
PO ___________________________________________ SLC Application Number ________________
Approved _____ Denied _____ Reason for Denial ___________________________________________
___________________________________________________________________________________________
Authorized by ____________________________________________________ Title, Date ________________
Payment of
$_________________ is hereby approved to the above surveyor.
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