AF - 46049�
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V�118�8 O�` Z'' 1'�iu83'� �II.
BUILDING PER11iiT
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1� � 6 3�. O�ce of INSPEGT08 OF BiT1LDING4S
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Architset Fridley, Minn h '=`� �8 <� 3.,�
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Builder `-�
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LOCATION OF SUILDING
No. ���� Street ��-�-�'� p� Part of Lot
�� � r � e' � .f , y `�
Lot _,. � Block_,,� Addition or Sut}Dfvieion _ -
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DESCRIPTION OF BUILDING
Front �° a Depth "', r;� � $eight �''� � 8torlea j' Manner oE Constructfon_ �'• .<;"�»
,
, ,�� �.. T ,<, �-�
To be used aa `,��� To be completed ���h °'�� .,� Eetimated Coet .�
�.
Parmit 1a hereby grantQd to � ..., _ ,� ,� � �::4 � ,� `.y ��.j� �"'
the builatn� desoribed ia the above statement. Thie permit 4s grauted
upon the espresa condltion that the peraon tfl whom it fs granted, and hie agente, employees and workmen, in a11
the work done in, esound and upon said iyuilding, or any part ther�f, shall conPorm 3n a11 respecte to the ordi-
nances oP F'ridley, Minn., regarding the conetruction, alteration, meiatena.nce, repair and movfn� of buildinge
wtthia the city limit�, and tbi$ permit maq be revoked at �ny time upoa violation oP any oP the provtsioas of said
ordinancea.
� ; � � ``V f inspector oP Buildings.
AGBEEMENT AND B�VVORN STATEMENT
In consideration of the isaue and delivery to me by the Inspector of Buildings of Fridley, of
the above permit, I hereby agre� to do the proposed work in accordance with the description
above set forth and according to the provisions of the ordinances of Fridley, and, being first duly
sworn, I hereby atate and say that the facts stated by me and contained in the above permit are
true as therein stated,
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Subscribed and sworn to before me at Fridley, Minnesota, t�R �'��' �-�
day of �?' � A-D 19 � '�
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sue�ecr PERMIT NO
c�ty of Fridley 14634
AT THE TOP OF THE TWINS g U I L D I N G P E R M I; '
S � RECEIPT .
� • COMMUNITY DEVELOPMENT DIV. �����
� VL �������
r � � PROTECTIVE INSPECTION SEC.
1 = �
( �"'1 � CITY HALL FRIDLEV 554$Z NUMBER REV. DATE PAGE OF APPROVED BY
�.---� � �•� 812-580-3450 910-F15 4/14/78 � /
JOB ADDRESS 1320 Hillcrest Drive N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 29 3 Moo�e Ld�C@ H11�.S SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
David A. Lucas 1320 Hillcrest Drive N.E. 571-0412
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Same
4 ARCHITECT OH DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENOINEER MAILADDRESS ZIP PHONE LICENSENO.
8 USE OF BUILDINd
RES lC�G'Il't]..d.�.
7 CLASSOFWORK
� NEW ❑ ADDITION �7 ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Remodel Kitchen
9 CHANGE OF USE FROM TO
STIPULATIONS provide smoke detector in upstairs ha.11way. Cover all flamable
insulation with �a inch sheetrock minimum.
TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
SEPARATE PERMITS ARE RE�UIflED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONINC3 S0. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STALLS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED.
WITH WHETHER SPECIFIED HEREIN OR NOT. THE aRANTING OF A PERMIT $�-�QOO �`.'rJO
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERM�T FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- 7, 5O
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $
PLAN CHECK FEE TOTAL FEE
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SiONA REOFCO 7 ACTO ORAUT ZEDAGENT IDAT >JVHEN P OPERLY VALIDATED THIS IS YOUR PERMIT
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SIGNA URE OF 0 NER IIF O NER BUIlDER1 � IDATEI BLDG INSP DATE
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' (�'�L"W, IILI�LRl17I �fl�, nllllI T I 0(a�, OR �EP/1I fZS )
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Oj��ta�R: �AV � � . ��1 C/� S I3UILllJ:Ii: .:I��7� � �
�aar��s: ��2o N�«ew�sT pR� l���ICJJ: 34r�
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Strcet: � .
Lo�c• _ i��j Hr,ocr.: ��_ nnnzTZa�a: Mo�,��.e .�� /'f�1��,a
COR11Ei. L'�.JZ': S21SIl�T' LOT: S;:TPACi:: SID1:Y11RDS:
Ai�plicant attzcl7 to Lhis fonn 7':•::� Certifj.cates of Survey of Lot and proposed
L-u�.ldir�g location drawn an t;-,ese Cartificates.
DESCRIPI'IOPd OF BUILDII�;G
To 13e Us ed t�s :
�„� /Mp �� L Fronts Deptha ' 13eight:
��TC��� Square Feet: C'�ibic I'eet:
I'ront:
Deptn: � Height:
� Square I'�et : �_ (11bic Feet:
Type cf Construction • Estimated Cost: $ ��00�
�i'o Be Coal�pl�ted: �p �fOw�1 _Tl�.�' Alt. A Alt. B
Prciposed Dxiveway i•�idth If New Upening Ts Desired S $
(S�� R�VERSE SIDE OF SH�ET}
�1-i� undersic.rned hereby makes appli.cation for a pexmit for the work herein
specified, agreeing to do all c�ork in strict accord�-uzce wi�th tlae City oi
k'zidle;� Ordin��alces and nilings of the Del?artment oi Buildings, and hereby
d�clares that all the facts anc? ref:resentatic�ns stated in �t�his application '
are true anci correct. See rever:;e si.de �ar , ac ' i:ion iniozm� on.
DnT�: 4%ly %7� _ szc��.�t�r.�.: � �
. . �Stipulat-ioiis: �: � a ,-
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£�UILDIP,G PEPt�1IT FFr SCHEVULE
SEC`s�tOIV ?.. The Inspector of Buildings s}iall, Leiore issuinq permits for the erecticm
of any building or structure, or for any addition to any existing building or structure,
or for any alteration or repairs to �ny existine� Luilding ur structure, upon a�plicatioi�
therefore, require the payment by the applicant for such permit of fees to the amoun�
herein belo�b set £orth and in the manner herein provided to-wit:
NEW CONSTRUCTION: Single Family Homes and Garayes: $4.00/1,000 cubic feei..
PLAN CHECK: 25 percent of building pei�nit fee�
UR2VEWAY DEPRESSION: (Concrete Curb Streets Only)
Alternate A: Renioval and replacement of concrete curb and
gutter only; Driveway width plus 6 feet x$14.50
Alternate B: Removal and replacement o� concrete curb and
gutter and install a 3 foo t wide approach with
6 inch depth; Drivevaay width plus 6 feet x$17.20
ADDITIONAL Ir�FC,R��IATION
For the purpose of computing fees for building permits, the cubical contents of any
building or addition, is determined by multiplying the ground area covere�. from a
point six (6) inches below the floor line of the basement or th� cellar to the
average heights of the upper surface or to the average height of the roof surface
of the riain gable of a pitched roof . �
For repairs or alterations to an existing structure, the fee sha11 be at the rate
of $3.00 i�er each five hundred dollars ($500.00) or fraction thereof in the cost
of all proposed work.
In no case sha11 the fee charged for any permit as se� forth in Section 2 be less
than $7.50 plus $.50 state surcharge.
VERIFICAT�Oiv F FOU�IDAiION
NOT�: Fermits �or construction will be issued a minimum of 24 hours from the time
af application to allow for proper review of the proposed structure and of the
construction site.
A Certificate of Survey of the lot, showing the iocation of the foundation once it
has been constructed will be required before proceeding with the framing.
_CCRTIFICA.TE OF OCC PANCY
Application for a Certificate of Occupancy shall be made ten (10) days prior to the
use or occupancy of any structure for which a building permit has been issued; and
sai.d structure shall not be used or occupied until a Certificate of Occupancy has
been issued.
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City of Fridley SUBJECT oP MIT NO.
BU ILDING PERMIT 16311 �
AT THE TOP OF THE TWINS - -
r
� � R�EIPT N
� ' COMMUNITY DEVELOPMENT DIV. �
i LV ������,
r j � PROTECTIVE INSPECTION SEC.
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' � /"'1 � CITY HALL FRIDLE� 55432 NUMBER REV. DATE PAGE OF APPROVED BV
�----� • •�� 612-571-3450 910-F15
7/31/81 � �
JOB ADDRESS 1320 Hillcrest Drive N.E.
1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED
DESCR. 29 3 Moore Lake �1�.13 SHEET
2 PROPERTY OWNER MAIL ADORESS ZIP PHONE
Da.vid A. Lucas 1320 Hillcrest Drive N.E. 571-0412
3 CONTRACTOR MAILADDRESS ZIP PHONE LICENSENO.
Same
4 ARCHITECTORDESIGNER MAILADDRESS ZIP PHONE LICENSENO.
5 ENGINEER MAILADDRESS ZIP PHONE LICENSENO.
8 USE OF BUILDING
Residenti.al
7 CLASS OF WORK
� NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 24' Round Swi�ing Pool
9 CHANGE OF USE FROM TO
STIPULATIONS
See stipulati.ons on letter dated July 30, 1981 hy Environmenta.l Officer.
SEPARATE PERMITS ARE RE�UIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SQ. FT. CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
ANY TIME AFTER WORK IS COMMENCED. NO. DWLG. UNITS OFFSTREET PARKING
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION 1 STAILS GARAGES
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS VALUATION SURTAX
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $�-�OOO $. SO
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE pERMIT FEE SAC CHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $%.SO
PLAN CHECKFEE TOTALFEE
$8.��
SIGNATUREOFCONTRACTORORAUTNOR12EDAGENT IDATEI � W LI ED THIS IS YOUR PERMIT
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SIGNATUREOFOWNEFUFOWNERBUILDER� IDAT�) --y DG WS DATE
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ROUND fl�DB. AREA �- . -�/U- � �.
(SG. FL1 'G1P. GP. 1�HL
16' x 48" 4616-23 201 � `�,�0 6.930 3701bs. ` '-=�r
18' x 48" 4618-23 248 : Z,7 � $.640 415 Ibs. 'a
340 ��� 92.100 485Ibs. '
24' x 48,' 4624_23 448 ��2,55�� q b.2� 560 Ibs.
x' 3 609 �7?r� 22,850 6601bs.
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g�g SUI�ACE APARCX D�. 11PPROX
01p1L blOD9, AREA G11L �AV1L SF�
�sc. �ra cnP. c� wxr.
24' x'16' x48" 4646-23 325 9,150 90,230 6051bs.
32' x 16' x 48" 4626-23 450 9 2,700 '15,060 845 Ibs.
40' x 16' x 48" 4606-23 574 46240 99,870 �A751bs.
41' x 29' x 48" 46� 9-23 756 21270 2627U �.100 (bs.
STEEL COMPONENTS °� . '
�0-Year I1mHed Warrcnfy on oll Stse1 ComponeMs `-' ` �
MassNe b" top seat • 6., slylized vertical suppod wHh fealure sMPe •�Y �PP� �� �� ��
seat rocidng • All heaW 9cu9e steel IMetlockin9 frame and M�A system • Rust protected wHh
bppp�r . yyap �� � ep�y �. p�:p�rx�ed skirruner and relum openU�s tor h�n
ease and Itner protection • Cortu-dbbed wall fiOf fleodbDiN cmd slrength •� tnbled snde �int wall
cannector ,�
UNER ;� �' -; . � � -
95 Year4lm11edWm►aMya� 20 M/iExpanda6lellner ,
„ ao0% Urproyerr�etd m tear resistce�ce • 90°b greaterter�ue atranglh • New err�boss►ng br �dra �1 protectton •
`� .
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_. �. Addltiorml chemicai and u(ha-vlolet re5lstance • 20 M91 e�cndabls (Urer fot cPflona� deeP swlmmin9 are° �Q���'Z� ,� �
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1981
CITY OF FRIDLEY
6431 UNIVERSITY AVENUE N.E., FRIDLEY, MINNESOTA 55432
Mr. David A. Lucas
1320 Hillcrest Drive N.E.
Fridley, MN 55432
TELEPHONE ( 612)571-3450
Re: S�aai�aning Pool Construction at 1320 Hillcrest Drive N.E.
Dear Mr. Lucas:
This letter is to make clear this department's requirements for the swivaning
pool construction at the above address.
l.
2.
3.
4.
5.
6.
7.
8.
As indicated, one (1) skiffiner app�oved by the National Sanitation
Foundation will be provided.
As indicated, one (1) inlet of approved design for fresh and/or
repurified water will be provided.
The filter and pump shall be approved by the N.S.F. and b.e of
sufficient capacity to provide a minimum turnover of at least two (2)
t�mes in 24 hours. This department reco�nends a turnover rate of
6 - 8 hours.
A deck of at least three (3) feet wide, measured from the pool waters
edge, shall be provided which extends completely around all private
residential pools. Above ground private residential pools may be
provided with decking of a mini.mum size of 4 feet by 4 feet at pool
entry points and provided that such decking has the approval of the City.
Fencing or other effective means including but not limited to walls
or buildings, acceptable to the City, sha7.1 be provided to positively
control all access to public and private residential swiaQning pools.
Fen cing shall meet the following criteria:
(a) The fencing shall prevent the entrance of children and be without
hand or foot holc3s. that would enable a person to climla over it.
(b) The fencing shall be at least 6 feet high and entrances shall be
equipped with self-closing and self-latching gates capable of
heing locked.
(c) Self-closing and self-latching devices shall be placed at the top
of the gate or othezwise inaccessible to snall children.
(d) The opening between the bottom of the fence and the ground or
other surface shall be not uwre than four inches.
An automatic chlorinator should be provided with a suitable test kit.
Al1 electrical and pluiabing installations shall be inspected and
approved by the City Inspection Deparfisaent.
Al1 overhead electrical lines must be a minimtmm of 10 feet horizontally
from the pool surface, and 18 feet straight line distance from the
waters edge. An alterna.tive is to bury said lines.
Mr. David A. Lucas
July 30, 1981
Re : S�ai�aing Pool Co ns tructi on
Page 2
9. The pool fill spout must be protected by a vacutiun breaker.or air-gapped.
10. Sui.table safety equi�ent to include but not limited to a ring buoy
and rope that is l� times the pool diameter, and shepherds crook pole
must be provided and maintained with the pool at all times.
Furthermore, these and any other requirements must meet the provisions of
the Fridley City Code, Section 115, Swi�¢ning Pools. The building pennit is
approved contingent on final inspections and approval by the City.
If any questions or proble�►s arise frcm this letter, please feel free to
conta ct me at 571-3450.
Sincerely,
.•,' ` i
, � _ n.� �,���� �
S J. �OLSON, R.S.
Environmental Officer
SJO/mh
CITY OF FRIDLCY
APPLICIITIQ'� FOf; RESIDEtdTI/l� BUILDItiG PGRt�IITS
(tJet•r, Alter�i;ions, AddiLions, or Repairs)
d11fdER: ��� r(� � e LI�( c� S
ADDRESS :� ZD i�/i�c � �=ST D�'
TEL N0: ,�� 1— d�-J 12_
�UILDER: �'�tJYd.P�1. �
ADDRCSS: ,�`�^g °
TEL IdO:
Construction Location
• STRI�T NO : ���� STREET: � l �G�-.�J' �- .
L07.': . �� SLOCK: ✓�' ADDITION : /'� �C L.i� lC'F � I L.�S
Corner Lot: Insicle Lot: Setback: Sideyards:
Ap�licant at�tach to this form two Certificates nf Survey of lot and
proposed building location drawn on certi.ficates to scale.
DESCRIPTIOid OF CQP�STP.UCTIOPJ
n �
/" Oc� � I'ront: 2L} r j?oua%1) Depth: y Height:
Squa�e.Feet: Cubic Feet:
Front: Depth: Height:
Square• Feet: Cubic I'eet:
y �?1 �-�( / .
Type of Construction : S G�? 1��? 1/�i� �e9p L Es�imaL-ed Cost: $/�� O � d 4
Zb Be Oor,�pleted: / O� f�S �
Alt. A Alt. B
Proposed Drive��ay Width Yf New Opening Is Desired: $� $
- ., SE� R�VERSE SIDE OF SHEET .
The undersigned hereby ma}:e� application for a permit for the �•vrk� hexein specified,
agreeing to do ,all work ir� str�ct accordance r�ith the City of I'ridley Ordinances znd
rulings of the Department of Buildings, and hereby declares that all the iacts and
representations stated ;n this application are true d corre
De�T�: � I Zq I8 I SIGNATUF.E : � �/ ° -
StipulaL-ions:
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• BUILDII�G 1'L-IZNII I I-L-I� :iCiif:)�UL� � .
SI�C'PIOI•� 2. �'i'tl� 7nc;��ectar. of- l3uilc?incJ ;::Il;i].J., bcfor:e i. �,ua.rig pennzt� for i_lic crr_cti.on
af ����y l�u�.J.cl:inc� ar :�t:.-uct:urc, or. �o�: ��na� adQi.i:i.on t:o auy er.i�ti.»c� l�uilcliny or s�:zucLur.c,
, c'»' i:��� a�iy ��Lt.arati�i� or, r.el�air.s L•o •any c.:i..L-ing }�ui.l_di,�i� or st�ucturc, uj��n nr�J�li_catioti
�thcr.:forc, rcquxrc Ui� Pa}►menL• }�y tlie app].i�ant: for. such ��er.mi.t of fees to Llic arno�ant
hcr�:in bc].a�•r sat far.th ancl 5.n 'r�1C mannez hcrein proviciccl L•o-�:�a�t: •
. 13i�1�7 CO2�5`PI;UCTI�IJ: Sing].e lamil.y Ilomc� and Gar.ac{es: ;4.00/1,000 cubic tecr. •
1'LFs?� CIIl:C1:: 25 pc:xcet4t: of bui.lcling }��ei-�nit. fee. .
URIV�t:AY ll�YP.L•'5Si0I•.: (ConcrcLc, Gtiirb �Lrcets Only) '
• A].iernai.e n: Itcmoval and rej�lac�ment of conerete curb and
guLtcr only; Driveway c•ridtli plus 6 feet x$13. �0
� Alternate II: Removal and rep�acem�•nt of concrete curb and
• � gutter and inst�ll a 3 foot ��ide approach t.�ith ��
' ,� 6 inch depth; Driveway width �plus G ieet x$15� 7�
• . �DDI i' I ��AI� I Nf�OR��1�1ZI0N
For the purl�se of co�tputi.ng fees for building permits,. L-he cubical contents of any
build�.ng or addition, is detcr.mi.ned by multiptying the ground area covered fro:n a
p�int six (6) inches below the iloor line of the basement or th� cellar to the
average heights of the •u�er surface or to the average heigrit of the roof. surf_�cce
oi the raain gable of a pitched rooi. �
Fox re�ai_rs or a].terations to an existing structure, the fee shall be at the rate
..of $3.00 Pcr each five hundred dollars ��($500.00) or fraction therc:af in the cost
of all proposed wor.k. . . -
In •no aase sha].l the fce cliarged fc�r any penni.t as set iorth in 5ecti�n 2 be less �
than $7.50 plus $.50 state swrcharge. � - "
VERTFICATIO�! �F F(1Ui�IDl1TI0fd
NOTE: Permits �or construcL-ion �vill be issued a minim� ai 24 hours from Uie time
�f application to al.low for prv}?er revie�a of the pro�osed structurc and oi th� .
construction site.
I� Ceri:ificate � of Survey of the l�t, shoc.�ing the location of the foundation once it
has been constnicted �.�ill be required before proceeding with the iraminq.
_ CFRT I F I C/�TE OF t�C�UPA�CY � �
' APplication ior a Certificate of Oceupancy sh�ll be made ten (10) d�ys prior to the
use or accugancy of any structure for !ahich a l�ui.lcling permit Izas been issu�d; and
said structuxc shall not be used or. occupied tuitil a Certificate oi' Occurzncy has
bcen xssued.
�
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• . - • � �. .
. •
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�,�� STATE OF MINNESOTA I3EPARi'MEIVT OF HEALTH
� .� ABANDONED M1ELL RECORD �
�
1. IOCATiOM Of YEIL M� eaEe blank �tPa oi knpwn) N0• H
County Nams
Toi+nship Name TomsAiD H Range tiumber Seetion No. FracLion 4. iIELL UEPTH (eompleted) Oate seeled
FRIDLEY � E k hof a
30 � 24 w'' 24 NENWNE 140 ft• MAY _ 12 � 199
s
Nuarerical Street Addreas and City af Well Location or Dtstaace frow Road 5. DRILLING METHOD (1f knaxn)
Interseciion 1�Cable tooT 4[� Revene 7[� Oriven 10C1 Dug
1320 HILLCREST DRIVE zp ++oiiow aoa sp Ai� ep so�a iip
Show exact laention ot rell
30 Rotary 6� Jetted 9� Power Auger
(!n section grid rith'•X') N Sketch map of wall locetion % 6. OBSTRUCTIONS
N /
/ Mell Obstrutted Q Yes � No
- �.__ _. � �,(2 ObsLructtons r�oved �Yes [❑ No If abstruetions cannot be
� ' rmooved, contact NDH
W' - - - • • -I- � - E 5O' betore sealing.
� ' ' ` � u�E�— �. use
` ' ,"r , 4„�,. 1}�Domestie 40 MonitoHng 8� Hent Loop
. . �. . . _�. . _ ., .. .. ,. _ I I � �O 2=( Irrigatlon 5� Public 90 Industry
' S' 1 3p resc wei� ep n„�ic+�i tap ca��iat
�---1 .aL--i 7[]A1r Candttioning 11[]
2. PROPER7Y OYNER'S NAME MaT•ling Address if dlfterent than 8. CASING(S)
DAVE & MARY io�2� aeHILLCRE$T�BDR. �Black �fireseed �Q
LUCAS zp c�i�. SQ Yelded
ERIDLEY, MN . 55432 3� Piasttc ep sr�iniess sr�e�
HARONESS OF
3. FORNATION LOG COLOR FORMIITfON FROM TO � t°• � �� 5 ft.
If not kno�m, indtcate formatlon log from new well o� nenrby well, in, to ft.
MUCK LAC • 0 15 9• SCREEN
�Screened rell troml� ft. eo1,�0 rc.
C LAY E D 1 5 3 0 (IY known)
❑ Open Hole from _ ft, to _ ft.
SANDY CLAY ROW 30 115 io. STATIC MATER LEVEL
SAND ROW 115 130 DRY tt.�eelo++ � aeove
land u ace Date Meesured �— 1 7— 9 7
CLAY LAC 130 142 11. u��u+�ao co►rot.�rtax
S AND S TONE RAY 1 4 2 1 4 5 1� Pitless Adapter � Found Buried
• '�Basement offset 5(]
30 Nell Pit
16. REMARKS, ELEYATION, SOURCE OF �ATA - CASINGS REHOYED. CASINGS PERFORATE�, ETC.
12. GRpUTING INFORWITION 6 BAGS
GEOLOGY WAS TAKEN FROM THE WELL AT : �t+eat tea�nt zQ sentontte �
N. E. MOORE LAKE & WEST OF OLD CENTRAL A E �rout materta�PORTLAND}�40 LaSURf$' su. yds
WATER LEVEL IN THE ABOVE WELL: NA NEAT GROUT __
�+�TF,' ��iT�,'� 1,1'',`iuL ��l.ri T1��CE�d: Nri 13. NEAREST SOURCES OF COHTIIMINATIaN
50 teet �_ et�ctto� CITY SEWER type
Hell dlsinfeeted beforo seeling7�Yes
14. PUMP '${Removed � Not Present
I1
Type: 1[I Submersible 3� l.S, Turbine � Reciprocating
�Jet 4� Centrifugal 6�
�AY � '' '�'`�" 15. EXISTING WELLS (Please sketch Iotatlons of abandoned antl
acH ve wells in remarks seetion o� on back.)
Othe� unused well(s) on prope�tYt ❑ Ye4 �No
__� - Ahandoned: � Permanent � Temporary � Rbt Fealed
�' 17. WATER WELL CONTRACTORS CERTIFICATION
���� TM s well was sealed under m urisdleti
� Y,S on and this re rt
Po
i: true to the best of my knowledge and belleP.
Accord i ng to M N Sta#e Regulati0tls E.
Lleensee Buslness Name Llcense No.
, 1
Add$�
5lgned +",- W. -' oate 5-14-92
U�� S_T�VE T.T D Dau —
FFiC1AL ABANDpNED YEII RECOQO (May be uaed for Property Transfer) Neme of Or111e�
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HEAT LOSS�_
sao eY_,�1_'���
Electrical Work 8y
TYPE OF HEAT GA
aIEIiTIPIG
�41R CONDITIONING
AIdD ELECTRlC, INC.
DATE HTG. INST.
STEAM SPACE HTR.
� r • �
`.� '� %R��./� � /
'` [�'l . ..
s� ,� r.•
///.
COPIgROLS
Heat Plua
Umit Set�n ld
Fen Settina o ��'
Pilot Type
Pilot Make
Pilot Model
PilotTiming ��-
L.W. Cut Off
Pressure P '� (►�✓.C. PeroentCO.. a
Input CFH o °� Percent OZ o/%O
Stack Temo. � / � Percent CO ����h+
IiOUSE HEATI6VG TEST RECORD
APT. FLOOR CITY SUBURB
•
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- �',�71'��'� �;��."L�'l�?�'
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CONVERSlON
V@�t $IZB • '�
KIND OF LIN SIZE NONE
Draft Hood Regularor �a�0/'��StQ Y�@.
Filters Size �ea� ' Number
Chimney Location Inside Outside
Chimney Construction
Smoke Bomb Wiring
Draft Test Tag
Door Pressure Lighting Inat. _1
Dete Tested
Company Teating
Name of Tester _
Pressure Percent COZ
Input CFH Percent OZ
Stack Temp. Percent CO
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