PRE 2010 DOCS3--�e,1151
City of Fridley, Minn. W? 8737
MU DING PERMIT
Date: March 28, 1966
Owner: Builder Homedale Builders
Address Address 3017 T,Vndale Ave. S., Mpls .
TA 5-2828
LOCATION OF BUILDING
No. 7-W9 _ Street Melody Drive K. Be _ _ Part of Lot
Lot 3 Block 5 Addition or Sub -Division Melody Manor, 4th
Corner Lot maids Lot X Setback 35, Sideyard
Sewer mevation 9 F 4. D k Mevation Z �cr
T'eI P a P Fo o T B M (
DESCRIPTION OF BUILDING
To be Used as:
Dwelling Front 46, , Depth . ��' �.8'height 2Q! _ Sq. Ft. 1,159 Cu. FL 9310A
Garage_ Front 9-4.t Depth ___20! -Height 10 1 Sq. Ft. _ Wig_ Cu. Ft. _43.89g
Type of Construction Frame Est. Cost —U&0-00 000 - To be Completed 7/3.A6
in consideration of the issuance to me of a permit to conotrad the building described above I agree to do
the proposed work in accordance with the description above t d and in compliance with ail provisions of
cudinances of the city of Fridley.
In consideration of the payment of a fee of $-28
00 ,permit is hereby granted to Aomedre
Bu31 OWN to construct the building or addition as described above. This permit is granted upon
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 respects to the ordinances of
Fridley, Minnesota location, cane on,
alteration, maintenance, repair and moving of buildings
within the city 11-1 and permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
ALLEN G. JENSEN Building Inspector
NOTIC&
Yhb pane& dos not caro do aanstne0m, hataMm for w1rh o, pbMbino, gas heathm awn a water. Be sun to sao
the Buddh>o Wspeder for apmft pwndk for thw ham
APPLICATION FOR BUILDING PERMIT
CITY OF FRIBLEY, MINNESOTA
OWNER'S NAME BUILDER
ADDRESS ADDRESS
LOCATION OF BUILDING
N0. STREET � _ PART OF LOT
LOT_ BLOCK ADDITION OR SUBDIVISI
CORNER LOT INSIDE LOT ✓""SETBACK ae_i SIDE -YARD
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Two Certificates of Survey of Lot and proposed
building location drawn on these Certificates.
To be used as;
DESCRIPTION OF BUILDING
Front •—DepthZZ : Height ;a--,
Sq. Ft. Cu. Ft
FrontrDepth Height
_ Sq. Ft. Cu. Ft.
Type of Construction !2d Cost
To be completed_ /'4, / U�
The undersigned hereby makes 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.
T
DATE SIGNATURE
(Schedule of Fee Costs can be found on the Reverse Side).
...
SUBJECT
PER
City of Fridley
15.2 4 2
AT THE TOP OF THE TWINS
BUILDING PERMIT
R
COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC.
2-
9,T706
1 �
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
i
1 �'-'1 CITY HALL FRIDLEY 55432
612-571-3450
910-F15
6679
JOB ADDRESS 7489 Melody Drive N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
3
5
1 Melodify Manor 4th Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Mr. Strong 7489 Melody Drive N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Dailey Homes 8510 Central Avenue N.E. 784-3910
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
6 USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW X7 ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Construct a 16' x 20' Addition to back of house
9 CHANGE OF USE FROM TO
STIPULATIONS
Provide outside combustion air for e�isting furnace. Install
fire alarm in corridor to existing bedrocms.
WARNING
ote digging call I0CA utilities
SEPERATE PERMITS REQUIRED FOR WtRIWI TELEMONE - ELECTRIC' GAS Etc.
HEATING, PLUMBING AND SIGNS. REQUIRED BY LAW
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
ZONING
SQ. FT.
CU. FT.
AUTHORIZED IS NOT COMMENCED WITHIN 60 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
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 GRANTING OF A PERMIT
$8,100
$4.05
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
PERMIT FEE
SACCHARGE
PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
STRUCTIO ORTE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTALFEE
o
19
$67.80
S N TU FCONTRACTORORAUTHORIZEDAGENT IDATEI
!' WHEN PROPERLYAALIDATED THIS IS YOUR PERMIT
BLDG iNSP IAT
SIGNATURE OF OWNER IIF OWNER BUILDERI (DATE)
CITY OF FRIDLEY
APPLICATION FOR RESIDENTIAL.BUILDING PERMITS /
(New, Alterations, Additions, or Repairs)
OWNER: BUILDER: e`1 gom eS
ADDRESS: ADDRESS: �/yo
TEL NO: (03 TEL NO: 3/y
Construction Location
STREET
NO: C% STREET:
LOT:
BLOCK: j
ADDITION:
Corner
Lot: Inside Lot:
Setback:
Sideyards:
Applicant attach to this form two Certificates of Survey of lot and
proposed building location drawn on certificates to scale.
Front:
DESCRIPTION OF CONSTRUCTION
Ik-1.
Depth: 0
Square. Feet: Cubic Feet:
H eight :
Front: Depth: Height:
Square Feet: Cubic Feet:
Type of Construction: IQ
To Be Completed:
Proposed Driveway Width If New Opening Is Desired:
Estimated Cost: $ --
81aci
Alt. A Alt. B
SEE REVERSE SIDE OF SHEET
The undersigned hereby makes 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.
DASIGNATURE:�e'vZ�
Stipulations:
Fd� '
W
�1IOU �.
32o'�( Z,S,'39 Teou
V . oo
T'° L1 ,ro:9'-� .
1'j20 (Louw.s ,
CITY OF FRIDLEY
APPLICATION FOR POWER PLANTS AND HEATING,
COOLING, VENTILATION, REFRIGERATION AND
AIR
CONDITIONING SYSTEMS AND DEVICES
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR:
RATr
TOTAL
,lob Address 59. ✓o/�
Furnace Shell & Duct Work
$12,00
$
* Replacerent of Furnace
7.00
$
Repairs & Alterations -up to $500.00
7.00
$
Department of Bi;jj4ngg
Re
Repairs & Alterations each add. $500!00
4.00
$
C;ty of Fridley
Tel. #571-3450
MECHANICAL ttiAIM AIR:
The undersigned hereby makes application for a permit for the work herein
Furnace Shell & Duct Work to 100,000 BTU
$12.00
$
specified agreeing to do all work in strict accordance with the City Codes
each add. 50,000 BTU
4.00
$
and rulings of the Department of Buildings, and hereby declares that all the
*Reaplace-.ent of Furnace
7.00
$
facts and representations stated in this application are true and correct.
Re:airs & Alterations -up to $500.00
Repairs & Alterations
7,00
4,00
$
$
Fridley Minn. ®i % 19Z•
each add. $500,00
,
=%I OR I87T i':ATER SYSTEM:
MMPR �
Boiler & Lines up to 100,000 BCU
$12.00
IND PF BUILDING
each addn. 50,000 BTU
4.00
$
,
Boiler only up to 100,000 BTU
7. • 0Q
S
pSFp AS
each addn. 50,000 BTU
P. -PA
S
e
TA F:P. FQMP7 TFD AFGuT � S
OIL BURNER- to 3 gal. per hour
each add. 3 gal. per hour
}A'Qq
$T}NFA
AQST�
GAS BURNER- from 100,000 BTU ro }gj,A9,A STK
5}Q.AA
$
' Imo' DN}R:JG PF#2M�T NQ. E'ER+SST N0. lCp
(over 199,999 BTU see Fee S0440
S
GAS FITTI::G FEES: -
1st 3 Fixtures x
$ A.QA
$
DDSAR$gTTQt� AF Fj)RNACE/$URETER
Aiditional Fixtures
Gas Range to 199,000 $TU x
#iFATTKG Rp I'CWNR I'TANTSt #I4t- Yl4ter{ Wam 4v- No.
AIR CONDITIO`ING
FAX HEATING SYSTEMS
$
Trade Name size No.
See Fee Schedule
VENTILATING SYSTEMS
$
ALTER.TIONS 4 REPAIRS
$
Capacity $q. Ft. FDR 13TU HP
State surcharge
$ .50
Total Connected Load Kind of Fuel
TOTAL FEE
$-Ud
BURNER - Trade Name Size No.
ROUGH INSP. REINSPECTION FEE
Capacity Sq. Ft. EDR BTU HP
Date ($10.00)
FINAL INS?.
Comp - —6�..� Cn•-
.are
Date
Signed By e!gS
APPROVAL FOR PERMIT !
Tel. No. Z ® ® 8
FEE FOR ANY HEATING PEEMIT $7.50 PLUS $.50 STATE SURCHARGE
*Attached stack verification form .
Building
Inspections
763-572-3604
763-502-4977 FAX
DATE__��'j
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
PROPERTY TYPE
PERM IT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DC
SIZE OF IMPROVEMENT
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
ING
Vinyl
❑ Alumin m
Q Other
BUILDING
PermitNo.• '"Z,Q _
RESIDENTIAL APPLICATION Received By
CITY OF FRIDLEY Date R M g R 2 5; 2 0 0
EFFECTIVE 11-08 a
OUR& ADDRESS
■•�ZVP
STATE LICENSE
FAX
SINGLE FAMILYMEW CONSTRUCTION
Two FAMILYmEw CONSTRUCTION
❑ BASEMENT FINISH p
❑ DECK
MTWWS
IN EXISTING OPENINGSea @10
OR FOR NEW OPENINGS -DESCRIBE SIZE OF
OPENING CHANGES &
TYPE OF.wINDOW TO BE INSTALLED
ALL FEES ARE BASED ON
COTAL JOB VALT
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
CONSTRUCTION 0 ADDITION
4CEIREPAIR O REMODELING
❑ HOUSE ONLY
❑ HOUSE & GARAGE
0 ATTACHED GARAGE
O DETACHED GARAGE
l7Sof it
❑ Trim
0 Fascia
V.
�' n' • ' ae�ls • a.
COST OF
SCSEDULL)
EXP DATE
O DRAIN TILE
O OTHER
BASEMENT REMODEL nNr3 sr M"•
I. Existing Floor Plan
.2- Proposed floor plan
3. Li0of structural members to be used
POP -NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS. & PORCM intvrrr.
I. Site Plan/Survey showing the existing structues
and proposed project. .
2. Two sena of construction plans
3. Energy Calwlations
$ a 3.7
_ °° VLX;UrANC;Y TYPE
'See Back Page for Fee Schedule
$
65% of Building Permit Fee
$
.001 times the total job valuation
$
.0005 x Permit Valuation Minimum $.50
$ 6 .
•$5.00 (State Licensed Residential Contractors)
$
$1825 per SAC Unit (Plans to MWCC for determination)
$
ft+6f}= ftx$21a$
$
$450 Conservation Plan Review
$
Fee Determined by Engineering
$
Agreement necessary( ) Non Necessary ( )
$ O
Make checksAagable-to• City of F+ j( ley Attach
THIS IS AN APPLICATION FOR A PERMIT NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate, that the work will be in oonfonnance with the ordinances and codes
of the City of Fridley and with the esotaConst uction Codes; that I understand this is not a permit but only an application for a permit and work is not to start without a
permit on site; that the work will be ' ce with heplan in the case of all work which requires review anndpproval of p .
SIGNATURE OF N\ -7 PRINT NAME 1 --DATE,/C'
APPRMI) BY '7W
Building
Inspections
763-572-3604
763-502-4977 FAX
SITE ADDRESS
THIS APPLICANT IS:
PROPERTY OWNER
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
PROPERTY TYPE
PERW= TYPE
TYPE OF WORK:
DESCRIBE WORK BEING DI
SIM OF IMPROVEMENT
■ •Y a
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
YOUR E-MAIL ADDRESS
PRONE ((pj /) 6 ISS-%=
STATE LICENSE # /
KJSINGLE FAMII Y/NEW CONSTRUCTION
❑ TWO FAMILY/NEW CONSTRUCTION
❑ BASEMENT FINISH
D DECK
❑ NEW HOME CONSTRUCTION ❑ ADDTITON
>SLMAIIVTEi`TANCE/REPAIR ^ ❑ REMODELING
ROOFING
NUMBER OF SQUARES
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
WINDOWS
IN EXISTING OPENINGS ❑Yea ❑No
OR FOR NEW OPENINGS -DESCRIBE SIZE OF
OPENING CHANGES &c
ARE
COTAL JOB VALE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
❑ HOUSE ONLY
❑ HOUSE &c GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
LOCATION OF WINDOWS
VALUATION, INCLUDING THE COST OI
(USING THE 1997 UBC FEE SCHEDULE)
FAX
`$ /A -7 Gl 7
Permit No.
BATE / A
❑ DRAIN TILE
❑ OTHER
F yrm
--rLwyni SQ FT
BASiMENr
REMODELING SUBMTf-
1.
Existing Floor Plan
.2-
Proposed floor plan
3.
List of structural members to be used
FOR NEW CONSTRUCTION INCLUDING DECKS,
ADDITIONS
1.
4go= MWM.
Site Pbn/Survey showing the existing a motures
and proposed project. -
2.
Two sets of construction plana
3.
Energy Calculations
• I. G See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ .001 times the total job valuation
$ .0005 x Permit Valuation Minimum $.50
$ •$5.00 (State Licensed Residential Contractors)
$ $1825 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$21=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ _ Agreement necessary ( ) Non Necesaary ( )
$ 11bd7:21 Mi" checks payableto• City of Fridley Attach
THIS IS AN APPLICATION FOR A PERMIT NOT. VALID UNTIL PROCESSED
I hereby apply foJdwi
and I aclrnoyvledge that the informab'on above is complete and acavraft; that the work will be in conformance with the ordinances and codes
of the Cityof FriMinnesota Consquction Codes; that I understand this is not a permit but only an application for a permit and work is not to start without spermit on sips; tham acco oe with the approved plan m the case of ail work which review and approval of .
SIGNATUREANT' • i1r%1 C7y}7�'1"A� PENTNAMB�—i / G�j'/ DATE -APPROVED DA � Id
Building
Permit Fee
BUILDING
ii 10 DI-? See Back Page for Fee Schedule
Plan Review
Permit NO.:W02 Ui
Inspections
Fire Surcharge
RESIDENTIAL APPLICATION.
� .001 times the total job valuation
'Received By'
763-572-3604
Lf 4 .0005 x Permit Valuation Minimum $.50
License Surcharge
$
c ) l l $5.00 (State Licensed Residential Contractors)
SAC Charge
763-502-4977 FAX
CITY OF FR IDLEY
Curb Cut Escrow
$
Date 350(
Erosion Control
$
EFFECTIVE 1-1-08
Park Fee
$
Fee Determined by Engineering
DATE 7- YOUR E-MAIL ADDRESS
$
Agreement necessary ( ) Non Necessary ( )
SITE ADDRESS
theo
Make checks a ahleto: City of nfldley Attach Stipulations
THIS APPLICANT IS:
0 OWNER ONTRACTOR
PROPERTY OWNER!
NAME: P10 arcriq
TENANT
ADDRESS: g O CITY
STATE ZIPy3�
PHONE.
CONTRACTOR
NAME
ADDRESS: ` 7i,1 06011b fl. CITY laiV-) STA ziP 5D�
SUBMIT A COPY OF
PHONE L[� o?(y FAX
YOUR STATE LICENSE
J ,
STATE LICENSE #__�% `7 EXP DATE
PROPERTY TYPE
INGLE FAMILYMEW CONSTRUCTION SIZE
0 TWO FAMILY/NEW CONSTRUCTION STORM
PERMIT TYPE
0 ADDITION 0 GARAGEISHEDWS
0 BASEMENT FINISH 0 ROOF 0 =RAIN E
0 DECK 0 SIDING 0 OTHER
O SWIMMING POOL
TYPE OF WORK:
0 NEW HOME CONSTRUCTION 0 ADDITION
0 MAINTENANCE/REPAIR 0 REMODELING
DESCRIBE WORK BEING DONE:
SIZE OF IMPROVEMENT
LENGTH WIDTH
HEIGHT so FT
�BF.R OF
0 HOUSE ONLY
SQUARES
0 HOUSE
BASEMENT
REMODELING SUBMTf
GARAGES
PROPOSED SIZE:
O ATTACHED GARAGE
0 DETACHED GARAGE
L
. 2.
Existing Floor Plan
Proposed floor plan
PROPOSED HEIGHT:
3.
List of structural members to be used
SIDING
FORNEW CONSTRUCTION INCLUDING DECKS,
0 Vinyl
OSoffit
D
NB
&PORCHES
O Aluminum
0 Other
0 Trim
Cl Fascia PytC� %"
1.
She Plan/Survey showing the existing structures
and
proposedproject
WINDOWS
`
2.
3.
3.
Two sets of construction plans
Energy Calculations
INEXISTING OPENINGS DYes
o LOCA ON OF
OR FOR NEW OPENINGS-DES
CME SIZE OF { le -D-1 pt, V
OPENING CHANGES &
e6
TYPE OF. WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ATX- sew 0-C ADLM DA QVT1k ^N XrAT TTAnTFd%1►T Tr Ti•.r rnntiwT—--
•r....�..... aa1%aJUV F11JV 1IIL1%JDJL OF LAnUl(ALVIP 1Ylt�1 N:K7AI Vt
((USING THE 1997 UBC FEE SCHEDULL
TOTAL JOB VALUATION $ C7I. 001 . OCCUPANCY TYPE
Permit Fee
$
ii 10 DI-? See Back Page for Fee Schedule
Plan Review
$
65% of Building Permit Fee
Fire Surcharge
$
� .001 times the total job valuation
Surcharge
$
Lf 4 .0005 x Permit Valuation Minimum $.50
License Surcharge
$
c ) l l $5.00 (State Licensed Residential Contractors)
SAC Charge
$
$1825 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow
$
ft + 6 ft = ft x $21= $
Erosion Control
$
$450 Conservation Plan Review
Park Fee
$
Fee Determined by Engineering
Sewer Main Charge
$
Agreement necessary ( ) Non Necessary ( )
Total Due
$
Make checks a ahleto: City of nfldley Attach Stipulations
THIS IS AN APPLICATION FOR A PERMrf NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and amruate; that the work will be in conformance with the ordbumccas and codes
of the City of Fridley and with the Mim►esota Construction Codes; that I tmderat and this is not a permit but only an application for a permit and work is not to start without a
permit on site; that the work will ba in accordanq wits th ppovedplanin the case of all work which requires review and of plans.
SIGNATURE OF/ih� PRINTNAME�/:( lJl'1�1 ®� DATE9 J
APPROVED BY
10
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 32017
Sealing
c
WELL AND BORING SEALING RECORD
County Name Minnesota Unique Well No.
tas
Anoka Minnesota Statutes, Chapter 1031 °r�Wblank 0 rot I Mo
T�rlc�le a
no.
Rangeo.
Z
Sec ion No.
Fr ction Vim. -r Ig.
S]] Nov
Date Sealed
Date Well or Boring Constructed
yITownship
1 19
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
1
,
05/28/14
unknown
GPS LOCATION - decimal degrees (to four decimal pla45
18
18ft
06' 15.48 N Ti9i 15 09.94
Depth Before Sealing ft
Original Depth ft.
Latitude Longitude
GEOLOGICAL MATERIAL
COLOR
Numerical Street Address or Fire Number and City of Well or Boring Location
7489 Melody Drive NE Fridley
QUIFER(S)
Ingle Aquifer ❑ Multiaquifer
STATIC WATER LEVEL
05/14/14
[Measured E] Estimated Date Measured
WELL/BORING
own
If , indicate estimated ion log from nearby well or bo ' g.
❑ Water -Supply Well ❑ Montt. Well
❑ Ern. Bore Hole El Other
ft. below above land surface
❑
Show exact location of well or boring Sketch map of well or boring
In section grid with 'X." location, showing property
lines, roads, and buildings.
CASINGTYPE(S)
N
-i--- -- -- --;-- tPlastic
f(" t
S eel ❑ ❑The El Other
i--- --.-- ---t- ---t-- T WELLHEAD COMPLETION
W EI
Outside: F] Well House At Grade Inside: El Basement Offset
-- i MIIe ❑ Pitiess Adapter/Unff KBuried ❑Well Pit
w. i pi+ El Buried
F-1
S — Xwe 11
El Other
El Other
It Miley
PR0ftt(&tNft6ftgCOMPANY NAME
CASING(S)
Diamet®r 0 Depth 15 Set In oversize hole? Annular spac mit 11 grouted?
G in. from to ft. El Yes No [I Yes 7No El Unknown
Property owners mailing address if different than well location address Indicated above
7489 Melody Dr. NE
Fridley MN, 55432
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown
WELL OWNER'S NAME/COMPANY NAME
SCREEN/OPEN HOLE
Screen from to ft. Open Hole from to ft.
Well owner's mailing address R different than property owner's address Indicated above
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill /No Obstruction
Type of Obstructions (Describe)
Obstructions removed? E3Yes ElNo Describe
GEOLOGICAL MATERIAL
COLOR
HARDNESS OR
FORMATION
FROM
TO
PUMP
Type
own
If , indicate estimated ion log from nearby well or bo ' g.
W,
,_., //
❑ Removed L�Not Present ❑ Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
No Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal
In. from to -ft ❑ Perforated ❑ Removed
in. from to ft ❑ Perforated ❑ Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑ No TN#
GROUTING MATERUU4S) (One bag of cement - 94 lbs., one bag of bentonite = 50 lbs.)
Neat Grout 0 18' 1
u
l
Grouting Material from to ft. yards bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
k
Other unsealed and unused well or boring on property? ❑ Yes ZNo How many?
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
id
Geology from 755 73 Ave N Fridley
This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained In this report
Is true tothebest ofknowledge.
Water level in above well: unknown
Renner Sons, Inc. 1431
Date water level taken: 06/05/2000
Licensee Business Name License or Registration No.
Well log from close by property
5/30/14
Unique # 644557a'`�
Certified Representak'voVignatigis
Arnie CoxCertified Rep. No. Date
LOCAL COPY
" 320173
Name of Person Sealing Well or Boring
HE -01434-14 IC#140-0423
5n3R