AF - 41609^
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City of Fridley, Minn.
BUILDING PERMIT
Date: ._.._._ JULY 7 s 1966 _..__.._._._
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�11'� 8916
Ovvner: _ Builder _`_.._ FERNDALE... BUILDERS .--._......._.._.._._..._..._
Adaress ___._.._.�.� __._____._.. Addresa � 15 05 _ FERNDAi�E AVENUE N E. �
FRIDLEY, MINNESOTA 55421
LOCATION OF BUILDING
542 ELY STREET N. E. p� or �t and W�st 20' of Lot 37
No. —_._.._..._� Street .r.._._... __._._. ._.._.._.._..._.._..__. _.
RIVERVIEW HEIGHTS _�
Lot .�.,.._� y.__ Block _.�._.K...v_.._._.._�. Addition or Sub-Divisio�n ...._.._.._._....�.___..._..._
Corner Lot -----.._._ Inside Lot ___.?�.._..�...__ Setback �.._35.� .....__._.._ Sideyard __.1 �� � _..._�
Sewer IIevatio� �....__.._.....— _._...._.._._ Foundation IIevation
DESCRIPTION OF BUILDING
To � v�a �: 9q� �¢�s'�
DWELLING ._._ F`ro�t 33� ._.. Depth _ 30�.— Height ._15�...._. Sq. F't. �� C;u. F't _�.._z408
_..._.—._.____�__...__.— F�o�t ._._ Depth _.�__..._.. FTeight ._.._.._._._ Sq. F't. _.�..._.._._. Cu. F't. _._..._._._
Z�pe of Construction _.._..._. � _.. Es� Cost _..._..�16_„_000 _...._........ To be Co:nPleted ___.....__...._.
LOT SPLIT APPROVED BY COUNCIL 4/20/64 - AGREEMENT FOR SPEC?ALS HAS BEEN
SIGNED.
In consideration of the isauance to me of a permit to co�stxuct the building described abave, I agree to do
tha ProPooed work in accordance with the descriptiou above set Porth and in compliance with all pravisions of
a�dtnaacea of the city of F�idley. , � .
In casudderatlon o! the PaYment of a fee o! �.23 . 00 ...._..._._.., permit is hereby grant�d to_.—_ FERNDALE w
B�m•DF,.:....R��.. __�. to construct the buildia8 or addition as described above. Thispe rmit ia granted upon
the exPress conditiaa that thepereo� to whom it ie 8raated and his agenta, emPloyees end worlunen, ia all wark
done in, around and upon said building, or an3'part thereof, shall contorm in all respects to the ordinances a�
Frlclley� Minaeaota re�ardin� lacatioq co�struct[o�, alterati�, maintenanoe, repair and mavin8 of buildinSs
within the dty limits and th3a permit may be revoked at aqY t�e u�p� violation of aqy o! the P�vidans o� ta�d
o�diaaace�.
CLARENCE BELISLE B�� ���
NOTIC�:
fw �n�11 r... eee ..wr 16. «aNwNl�. N�+.IMII�e t« wMM/. r�a w�••w.. K w.1... a wr. fe .»
1M Wll�ly In�N� hr Npral� MnnIM fer Nua hw.
F
APPLICATION FOR BUILDING PERMIT
CITY tlF FRIDLEY, MINNESOTA
OWNER' S NAME BUI�DER �E�('NO4 �E /fiY. �,QE�; S
ADDRESS ADDRESS �s o�-- /�?�w•��'G�
LOCATION OF BUILDING
N0. ��- STREET ��, � PART OF LOT
P
LOT_3�, l� ��BLOCK__� ADDITION OR SUBDIVISION_ �-'����s.'E.✓ �t�', �'����.a�„�,
CORNER LOT INSIDE LOT v SETBACK SIDE-YARD
SEWER ELEVATION FOUNDATION ELLVATI�N
Applicant attach to this form Two Certificates of Survey of Lot and proposed
buflding location drawn on these Certificates.
DESCRIPTIOft OF BUiLDING
To be used as;
r
:, *°�Lr` /"y'"yG}� l.��e*FtL,�G-' Front J� � Depth�Height /S" �
Sq. Ft. 'y y C Cu. Ft. �yo�
Front Depth Height
Sq. Ft. Cu. Ft.
Type of Construction /'�i,��^a E' Estimated Coet �/L u�o�? u�
To be completed_ S' C-� � l jyC�
1
The undereigned hereby makea application for a permit for the work herein
specified, agreeing to do all work in strict accordance with the City of
Fridley Ordinances and rulings of the Department of Buildings, and hereby
declares that all the facts and representations stated in this application
are true and correct,
DATE_j�y y,� /�� L SIGNATURE �'t'�l� � _
(Scheduie of Fee Costs can be found on the Reverse Side)
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BUILDING PERMIT FEE SCHEDULE
SECTTON 2. The Inspector of Buildings shall, before issuing any permit for
the erection of any building or structure, or for any addition to any existing
building or �tructure, or for any alterations or repairs to any existing
building or structure, upon application therefore, require the payment by the
applicant for such permit of fees to the amount teerein beZow set.forth and in
the manner herein provided to-wit;
2.1. For any such permit for the erection of any fire-proof building,
other than a garage, warehouse, factory or grain elevator, or for the erection
of any fire-proof addition, for similar occupancy, to any existing building,
shall be at the rate of $1.40 for each one thousand cubic feet, or fraction
thexeof, in such cubical contents.
2.2 For any such permit for the erection of any fire-proof garage,
warehouse, factory or grain elevator, or for the erection of any fire•proof
addition, for similar occupancy, to any existing building shall be at the
rate of $1.25 for.each one thousand cubic feet, classified as "fireproof"
by Section 502 of the Minneapolia Building Code.
HOIISES
2.3. For any such permit for the erection of any non-fireproof
building, other than a garage, warehouse, factory or grain elevator, or
any non-fireproof addition, for similar occupancy, to any existing building �
permit $1,0� for each one thousand cubic feet.
GARAGES
2.4. For any such permiC for the erection of any non-fireproof garage,
warehouse, factory or grain elevator, or for the erection of any non-fire-proof
addition, for similar occupancy, to any existing buildiag or for each such
building or addition - ninety ceats ($0.90) for each one thousand cubic feet
or fraction.thereof, in the cubical contents thereof with the minimum of $4.00.
For the purpose of computing fees for building permits, the cubical contents
of any building or addition to a uniform height throughout by multiplying the
ground area covered fram a point six (6) inches below the floor line of the
basement or cellar to the average height of tha upper surface or to the average
height of the roof surface of the main gab.le of a pitched roof.
2.5. For repairs or alterations to an existing structure, the fee sh�ll
be at the rate of $3.00 per each Five Hundred Dollare ($500.00) or fracii�n
thereof in the cost of all proposed work.
2.6. , In no case shall the fee charged for any permit as set forth in
Section 2 be less than $4.00.
STORM REPAIR DAMAGE FEES: .
Resideutial: Estimated Cost of work up to 55��,!?� - S5,^�
Estimated Coat of work ovex .'' �� :. ':? s;; k;,, F 0
Com�ercial; EstimatecY"'bst of wo*'�. •��� �� ''� . , „�) ., '� r�,�
:,'-
, __ . Estimated .,ost of u-u�:c orc:r � �t;i:�Ui� - �' J .
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1 _ �� ��'����.�� � �+� ���°�'�i(
. MIL;�ER W. C��l.EY � ASSOCIA,3�S
CONS!lLTING CIVIL ENGlPJEERS—t�AND Sf1RVEYORS
500 W. HWY. 96 18 FOURTH AVE. S.E.
ST. PAUL 12, MiPiN. ST. CLOUD, MINNESOTA
I 454-3301 B� �-��$�
I t�ereby certify that if�is survey, plan, or report was prepared by m� or under my direct supervisian
and that I am a duly Regissered Land Surveyor unuer the laws of the State of Minnesota.
� .�f � � / � / Re No. `' �'-'_ _Date '` _ . _ :' ; '.:�`; °
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� CR�N�OYMS HTG. 8c AIR COND.� INC. �ob Name�������'� ����5
, n.76� ��o �.i.r �..i....�+. �u....�.i�. �a �. �'c� 2 �G� �,�— �/�L.F�
�:. NtA� L,O� <ALeYLAt10/1� Job Addres
A.S. .V. ,
Weatherstrips Construction No. Inaulation
Guide
Windows Doors Reference Out. RfaU Int. Wall Ceiling Roof Floor Kind How Applied
� Yea—No I Yes—No 19_
: Fl. Room Length Width Height / F7.� Room Leagth l� W�dth/d Height
Windows nd Doon—Crackage and Area Windowa and Doors--Cracl�age and Area
Nidth Hei�ht No. ot Llnaal tt. Area Wldth � Hefibt No. ot Linql [Q Aroa
No. ot pane o[ Dane U�ht■ ot crack W [t• No. ot pane ot pans ll�ht� ot enct p. tt.
? � /_ � �v /q 2r� % Z�' G Y /�
In6ltration
Glaaa
Fsp. wall
Net exp. w
Int. wall
Ceiling
Floor
, Total Btu.
. No. I of
_ �_
_ In6ltratan
, Glau
—�e;
ft. E.D.R. or �q. ins. W.A. Leader ana
R�� �p�h w�h
� Doors--Crackage and Ana
Hal�ht Na. ot Lia�al it. Are�
o[ pans li�st� ot cracic p. ft
� S �
�•c v / l'
_ Exp. walt
� Net exp. wal���
_ Int. wall
Ceiling .Z O. G K
_ Floor ,,� a � G: �
_ Total Btu.
C
1
�
_ Required sq. k. ED.R. or sq. ias. W.A. Leader arca
FI. Room � l.ength,�,o W;dch /
_ uidows and Doors--Crackage and Area
Wldth Hei�At Plo. o[ IJaul tt. Ares
� v� ..� ...... � n� n.w. -� Ifrhta et c�ack �a. tt.
! l�d'iltrat'an
� c��
� E:p. wall
r Net e:p. wall �
� int. wall
� Ceiling W...�
�' Floor ��. 4. �
� Tbtal Btu.
p j
�
�
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iuired W. ft. E.D.R. or sq. ias. W.A. L.eader area
�
Coef.l Btu
Z y In6ltration ..Z� b
� G1..� Sa
Fsp. wall
� Nec e�. wall 2�— � (E � = f.o o csD
Int. wall
� ° Ceiling
Floor Z / o � ZO O
� Total Btu.
� Required u�. k. E.D.R. or tq. ins. W.A. Leader area
Fl. �l m I t�� w� � 2.���
Windows and Doors�—Cracicage aad Area
Wldth Hef�ht No. o! Llaeal tt. Ares ���
No. ot paae ot pa� Il�ht� o� � Ic q. tt. �
Z y � Z�
o In6ltratioa
'o Glass �
Exp. wall
o Nec e:p. wall = S � O
Iat. waU
� Ceiling
. 0 F1oor 'J ! Y
� Total &u.
Reqnired p. k. E.D.R. or sq. nis. �f/.A. I.e+�der uea
— Fl. tt� � c,�� Z- w� �—
Windows and Doors--Crackaae and Area
Width �1�6t Na ot L1n�a1 tt. Aru
Na ot pao� ot.pan� 11�6b ot crack q. tt
-� Z:' �
Bm �
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z 3 s� c�.0 d
Eap. wall
'� b Net ezp. w.u2 s — %
Int, wall
..--� Ceiling
Floor 2- 1�
Total &u.
Required sq. ft. E.D.R or sq. ia:. WA. Leader area
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CRQN�OMS HTG. & AIR COND., INC. �ob NameF��N��L� �'D�S'
D-S6 : M10 Exulsier ierl��ard. Miee�epelis 16. Minn. , f L,/ ��/ �
�:s NSAt LO� <ALNLA�IONi Job Address �Y'Z � l `ST ���
Weatheratrips A�' 'V' T Conatruction No. � Iasulation
Guide
Windowa I Doors Reference Out. Wall Int. Wall Ceiling Roof Floor Kiad How Applied
Yea—No Yes—No 19_
Room Length�" Width / Height Fl.� Room Lengt6 VNidth Height
Windows and Doors--Crackage and Area Windowa and Door��—Craekage and Area
�Yldth Hei`ht No. ot Llnesl tt. Area W�dth Hel�bt No. o[ Lln�al tt Araa
No. ot Dane ot vane 116ht� ot cracic p• [t. No. of pan� o[ yans lt�LU ot enck p. tt.
l � � �w f.i� � �1f�
Coef.
Infiltration Y
Glass
F:�cp. wall
Nec esp. wall - -,Z, = ` . ,
Int. wall ,3 $' i.
Ceiling .3 J�( / (.
Floor ..�-�-
Total Btu.
Required aq. ft. E.D.R. or �q. ias. WA. L.eader arca
Fl.� Room L.ength Width
Windows and Doors—Crackage aad Ana
Wld h Hsl�ht No. ot Liaalal [t. Aru
No. ot wns ot oane Ifcht� ot crack �a. tt
i
Ia6ltration
Glaa
Eap. wall
�—
Net exp. wall
Int. wall
Ceiling
Floor
Total &u.
Required aq. k. ED.R. or sq. in:. W.A. Leader area
Fl.� Room
Windows and Doort--�
Idth Rel�ht
No. ot nan� ot pane
�
In6ltrataa
Glaa
Exp. wall
Net exp. wall
Int. wall
Ceiling
�loor
Tbtal Btu.
aad Arca
n.:� «. wres
cnck �a. !t.
Required iq. ft. E.D.R. or sq. ins. Q/.A, Lwder area
� ��
��
����
�u
�
Iu6ltration
Glw
Fap. wall
Net e�p. wall
Int. wall
Ceiling
Floor
Total Btu.
Raquired W. k. E.D.R. or sq. ins. WA. Leader ana
FI.� Room � l.ength Width
Windows and Doon—Crackage and Area
Wldth H�t�ht No. ot Llnetl [t. Area
No. o[ Dao� ot pan� ll�hb ot cnck �. tt
Infiltration
Glass
Ezp. wall
Net e�p. wall
Iat. wall
Ceiling
Floor
Total &u.
Requued �q. k. E.D.R. or �. ins. a/.A. Leader area
Fl. t� � �� w�
Windovvs aad Door�—Crackage and Area
N� o�t w� ot�wa� Ilrhb ot�ce ck t�e. tt.
In6ltration
Glaa
Esp. wall
NN ezp. wall
IaG wall
Ceiling
F7oor
Total &u.
Required sq. k. E.D.R. or sq. ia:. W.A. L.eader aria
a[Y
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City of Fridley, Mi.nn.
BUILDING PERMIT
Date: __.___.._.. July 28, 1967 �.�_`.^
Arthur Ohotto
Owner: _..._......__...---...___._._.._..._.---.
Builder _.._..._Sa�e
Address ._542...._..._.....51_Y._St,...:N.... E_.....__.._._......_.------••-----.._. Address
3�G�:�
1�1� 9 3'7 �I
LOCATION OF BUILDING
No. ..�542-.--------_._. street ._..-------.E�.._.St�----..---.....____....._.____.---.---------------..-------.... Part of Lot ....._......_...___.._._____.._.__.._..__.______
Lot .__��.,.3�.,.....3J Block _--------K----•-••--•-•-------.......--- Addition or Sub-Division ...----......Ri.v.er.�r.ieyz_Heights_._.__._--
Corner Lot —_......._..._....._ Inside Lot •--•--•------.......----•-----... Setback .__._..._....---••---.-----... Sideyard
Sewer Elevation _.---....�----•-•-----.._.__._._..._.._.._._...----•--------•---._._ Foundation Elevation ------..___..
DESCRIPTION OF BUILDING
To be Used as:
_.yGarage_.._.._...._....__ Front _._._24�.._. Depth .....24.�..---- Height ....._._1.�.�_.. Sq. F� ..576...__ Cu. Ft 5760.._
._.__._...•---_._...__._._.---_...._. Front __._..-----....__ Depth _._.___..._..._.. Height ....._.••----••----_ Sq. Ft. _.._....._..._.. Cu. F't. _.._...�_.�
Type of Construction _..._Frame.._..._....._...._...__.. Est. cost ...........�65_0..00........_.....--- To be Completed _....�T.3k.13L_.?.8.,--1.4.�L$
In consideration of the issuance to me of a permit to construct the building described above, I agree to do
the proposed work in accordance with the description above set forth and in compliance with all provisiona of
ordinances of the city of Fridley. �__�����-�,�,_ Q�i�
In coz�sideration of the payment of a fee of �._.._9 . 00 _���t is hereby granted to__... Arthur ��
Ohotto .. to construct the building or addition as described above. This permit is granted upan
....__..........____..._...._...�.._....._ . _. __
the express condition that the person to whom it is granted and his agents, employees and workmen, in all work
done in, around and upon said building, or any part thereof, shall conform in all respecta to the ordinancea of
F�id1eY, Minnesota regarding location, construction, alteration, maintenance, repair snd moving of buildings
within the city ]imits and this permit may be revoked at ar�y time upo� violation of any of the provisians of sa�d
ordinaacea
CLARENCE BEI,ISLE B�� ��
NOTICE: �
This p�rmit doa nw eovH th� eonsleueMoe, 6utdlNien for wieiny. plumbfn0. oa h�aNaa, »w�r or wN�r. !� sun to aM
�h� Building Insp�eror for ap�rah p�rmits for fhu� ihms. '
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c�.� o� ��w:�:,��, r:�r��;�s��
--�e� .� •i[��� ( / v
OWNER' S NAME R`.; i:'t �DER
Annx�ss _.:�.� � � �si�}��....�.�._. an��.�ss
L�JCA; �:ON QF BUILDI:+G
r10. �� oZ STR�ET .�� ����,� �s �• PART 0� LOT
�5 - 3 +6 �--
LOT � 0 e.� BLOCK AD�ITIOi�t OR SiT+3D�VISION �� � �'��
3
CORNER LOT INSIDE Lt}i SETBACK SIDE-XARD
SEWER ELEVATION FdUNDATI033 ELEVATIOi�
Apglicant attach to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Gertificates.
DESCRiPfiIO�t OF BUILDING
To Be Used Ae ;
� � Front � Depth o� Height / C�
Sq. Ft. ��.6 Cu. Ft. �� % C �
Front Depth Height
Sq. F�. Cu. Ft.
Type of Constructi4n_,� r, ,ti,�,�t,Pj Estimated Cost__ �� ,�� �—
To Be Complete3-- -- -� � '� �� � .
r
The undersigned hereby makes a�oiication for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City of Frid?ey Ordir.ances
and rulings of the De��rtment of Buiidings, an3 tsereby dacl�res that all the facts
and representations st2ted in this app:ication are true and correct.
DATE �j �1 q 6 SIGNATURE '�;,���
(Schedule of Fee Cosrs can be faund on the Re��exse Side).
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BliILDING PEP.rIIT FEE SCHEDULE
SECTION 2. The Inspector of Buildings shall, before issuing permits for the
erection of any building of structure, or for any addition to any existing
building;or structure, or for any alteration or repairs to any existing building
or structure, upon applicalion therefore, require the payment by the applicant
for such permit of fees to the amount Y:erein below set forth and in the manner
herein provided to-wit: .
Uniform Building Code: Type 1,2, & 4- $1.75 for each one thousand cubic feet, or
fraction thereof, in such cubical contents. Type 3'�: 5-$1.50 for each
one thousand cubic feet.
For the purpose of computing fees �for building permits, the cubical contents of
any building or addition to a uniform height throughout by multipluing the ground
area covered from a point six (6) inches belo��� the floor line of the basement or
cellar to the average height of the upper surface or to the average height of the
roof surface of the main gable of a pitched roof. .
For repairs or alterations to an existing structure, the fee shall be at the
rate of $3.00 per each Five Hundred Dollars ($500.00) or fraction thereof
in the cost of all proposed work.
• In no case shall the fee charged for any permit as set forth in Section 2 be
less than $5.00. �
NSSSD Connection Charges based on location- Area 1 or 2.
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1602 SELE3Y AV[h:U�. ST. PAUL 55f04 TELEPHOt�'ES� 333-6475
. SCO.L�: 1 INCH—�`� --- F�ET 742 GUILDERS EXCHANGE GLDG.. MINNEAf'CLIS 55402 .
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�CCATION- --------'L.---� -------------------.
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CERTIFICATE OF LOC�T.IO:� OF i3liII.DING
. �
I hereby cei•tify that on_ _ 1��-11____- —19 '�_6
I macle n sur�-e y• of the location of th^ builctinn�(s) on the
abo��e describcd property and that the location of said
build�ng(s) is correctt�t sl�o�vn n the �^•e p]at.
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CERTIFICATL OF SL'R�'EY
I hcreby certify� that on 19
i sur�•cyeci the propei•ty dee.cribed above nnd that the abo�-e
I;'a�is'a�COrrect repres��:tion of sa:d survey.
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"�JOHN J. RYAN, REGISTERED SURVEYOR. No. 4489
,
Flora, John
From:
Sent:
To:
Cc:
Subject:
Flora, John
Friday, July 30, 1999 10:38 AM
Bolkcom, Ann
Burns, Bill
542 Ely
�'�./�1.��� �-�
I talked to Mr. Ohotto about the width of the first block of Ely. He lives on the second block. His concern is the width of
the street and the cars parking near the corner of ERR. The ROW on the first block is 30 ft. with a 22 ft road. The second
block has a 40ft ROW and 26 ft road that he's saisfied with. I suggested that he get a neighborhood petition for either
additional 10 ft each side ROW and a curb assessment or a NO PARKING restriction on the block. He's not real thrilled
to walk a petition as he thinks the neighborhood is not as sensitive as he is.
john G. Flora
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WELL OR BOWING LoCa7loN MINNESOTA DEPARTMENT OF HEALTH MinnesOta Well"and dng
Gqunty Name WELL AND BORING SEALING RECORD ���ng No. H �, �,��� �_
Minnesota Unique Well No.
�� Minnesota Statutes, Chapter 1031 or W-series No. .{°
� hema w� e �a �m.,q �aeFi.�,�s�''
Town������, Township No. Range No. Seclion No. Fraction (sm. -s Ig.) Date Sealed Date Well or Bonng Constructed
d.° �L � � � .� r.�'�u �. �� 1 �3 � �� � 9.rS� � i�
Numencal SVeet Address or Fire Number end City ot Weli or Bonng Location 3
�e�� �� �°� '*� �j Depth Bebre Sealing `�'�� it. Onginal Depth � n.
Show exact I�ation of well or boring Sketch map ol well or bonng ApU1FER(S) STATIC WATER LEVEL
in section grid with 'X'. � location, showing property � Single Aquifer ❑ Multiaquifer
lines, roads, and build'mgs.
N WELUBORING � Measured ❑ Estimated
� � � �. � Water Supply Well ❑ Monit. Well
_T' �T_ _ __ _�1�� .
❑ Env. Bore Hole ❑ Other � ft. � bebw ❑ abwe land surtace
W --r- -f- -i-- --i-- E CASIN(i TYPE(S)
� �
--1-- ---- -i-- -i-- fi � Steel ❑ Plastic ❑ Tile ❑ Other
, I , , y�,� �
--�- --i-- -i-- --i-- C/iSIN�)
' Diameter Depth Set in oversize hole? Annular gpace InitlaAy grouted7
n a
' S �
� � „�� � �n. hom � to �'� ft. ❑ Yes � No ❑ Yes ❑ Na ❑ Unknown
PROPERTY OWNER'S NAME In. hom to ft. ❑ Yes ❑ No ❑ Y� ❑ No ❑ Unknown
- - --- --- - - - - - — -- - -- - _ � __ _�
Property awners ma�ling a�lrese il diHereM than weil Ixation address irM'iceted above. in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
��� �,� ��� � SCREEWOPENHOLE
���� � R'JK���� Screenfrom to (t. OpenHo7STPoSIS ���to fl.
OBSTRUCTIONS
WELL OWNER'S NAME ❑ RodslDrop Pipe ❑ Check Vaive(s) ❑ Debris ❑ FlII � No Obstruction
��
Weu owrrer's mauing amress n dNferent tlren property awner's eddresa inmea[ed ebove. Type of Obstructions (DesCribe)
- Obstructlons removed? ❑ Yea ❑ No Describe
PUNP
T� ���
OEOLOGICAL YATERIAL COLOR �RDNESS OF �OM TO 9Iy Removed ❑ Not PreseM ❑ Other
FORlAA710N METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASIN�S, OR CASINO AND BORE HOIE:
lf nof`k'riuwn. f� effihna0ad tormation log hom nearby we0 or boring.
'�No MnWar Spece Ex(sts
�•� ❑ Annuler space grouted wrHh hemie PiPa
Casing Perforetlon/Flemovel
In. hom ro ft. ❑ PeAorated ❑ Remaved
in. from to ft. ❑ Perforated ❑ Removed
Type of peAoraror
❑ Other
GROUTINO MATERIAL{S) (O�re bag of cement = 94II�,a., o�re bag of bentonke = 60Ibs.)
Grouting Material nom �`�� to � e. yards �` bags
from to ft. yards be8s
from to ft. yards bags
from ro tt. yards bags
IEYARKS, SOURCE OF DATA, DIFFlCULTIES Ild ^��ALING OTHER WEL6S AND BORINGS
��` ��� �� � ���� Other unsealed and unused wetl or boring on propertyT ❑ Yes No How meny7
LICENSED OR REiiISTERED CONTRACTOR CERTIFICATION
�'� �r•-+ ��� ���' �� g'fhis well or boring wfls sealed in axordartce uhlh Minnesote Rules, Chapter 4725. The informaUOn coMeined In thia repoR ia
��* �� ��, +` ` Q����`i�� e M the best of my Imawledge.
� s�%�',� /�;�_���� ,, -�_ ��"�° '� E° ��a4 ��.��..�F
- -' '! _' Co�ecror B e L+oerrse w RegLstrflKon Pvo.
- -- � � _. D �� . �R.3.��r1/[ VY
� . Authalzed Represente e SlgrtaNre Qe�e
K�#7C�i ��.�`+�''•^'��.. z-�`���� [��'��
���A� ���° f u� r� ���� Neme ol Person SeeUng WeG or Boring
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