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PRE 2010 DOCSVillage of Fridley, Mum. N? 166 BU11A)ING PER3ffr Office of INSPECTOR OF BUILDINGS Owner Architect Builder % Fridley, LOCATION 9F BUDDING No. Street Part of Lot Lerrs 7 Block Addition or Sub -Division DESCRIPTION OF BUILDING Fro'Aff— D� Height Stories EVV Manner of Construction To be used as ' Its.^10 To be conl)ppetedEstimated Co Permit Is hereby granted to to the building described in the above statement. This permit Is granted upon the express condition that the person to whom it is granted, and his agents, employees and workmen, in all the work done in, around and upon said building, or any part thereof, shall conform In all respects to the ordi- nances of Fridley, Minn., regarding the construction, alteration, maintenance, repair and. moving of buildings within the city limits, and this permit may be revoked at anytime upon violation of any of the provisions of said ordinances. �pector of Buildings. AGREENMNT AND SWORN STATEMENT In consideration of the issue and delivery to me by the Inspector of Buildings of Fridley of the above permit, I hereby agree to do the proposed work in accordance with the description above set forth and according to the provisions of the ordinances of 'ley, and being first duly sworn, I hereby state and say that the facts stated by me F q`l - 11, conta!,zi in .the,. he_above permit are true as therein stated. Subscribed and,,sworn to before me at Fridley, Minnesota . . . . . . day of A.D. Village of Fridley, Mm. BUILDING PFAMB T N° 207 mice of INSPECTOR OF BURMINGS _a Owner _.. ,� 5, ►r: <., w Architect" Fridley, Minn., ! , Builder s� LOCATION OF BUILDING No. Street Part of Lot Lot Block Addition o Sub -Division DESCRIPTION OF BUILDING Front Pe th ' Rei ht Stories � e �1+, �g Manner of Construction gym' a �";��' Estimated Cost To be useda To be completed Permit is hereby granted, o the building-tdescribed in the above statement. This permit upon the express condition that, a on to w0om it is granted, and his agents, employees and workm the work done in, around and upon said building, or any part thereof, shall conform in all respects to nances of Fridley, Minn., regarding the construction, alteration, maintenance, repair and moving of within the city limits, and this permit may be revoked at any time upon violation of any of the provisio ordinances. C-%' i % � 4P-9Inspector of AGREEMENT AND SWORN STATEMENT In consideration of the issue and delivery to me by the Inspector of Buildings of F the above permit, I hereby agree to do the proposed work in accordance with the de above set forth and according to the provisions of the ordinances of Fridley, and, being sworn, I hereby state and say that the facts stated by megontained in the above pe true as therein stated.' Subscribed and sworn to before me at Fridley, 1 day o+' .D. 19J)---') 1 -1 Date: City of Fridley, Minn.. BUILDING PERMIT July 23, 1965 VIVIVi171MOWN- -9 lr`�11��t7il Builder Address 521 Mississippi St. N.E. Address Fridley, Ninmesota LOCATION OF BUILDING No. 5 21 Street MISSISSIPPI STREET N. E. Part of Lot Lot _ Block Addition or Sub -Division Christie Corner Lot ._ Inside Lot Setback ____ Sideyard Sewer Elevation Foundation Elevation N? 8258 DESCRIPTION OF BUILDING To be Used as: Front — Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. F't. Cu. Ft. Type of Construction Fast. Cost —$18, 000.O0 To be Completed REBUILD HUE TO STORM DAM&GE CHECK PIANS CAREFULLY BEFORE BUILDING in consideration of the issuance to me of a permit to construct the building described above I agree to do theproposed work in accordance with the description above set forth and in compliance with aft provisions of ordinances of the city of Fridley. In consideration of the payment of a fee of $ 10000, permit is hereby granted to WAMCE ERLAMSON 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, Minnesotang location, construction, alteration, maintenance, repair and moving of buildings within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinance. AIM G. JENSEN Building Inspector NOTICE: "k permit doss net emu the eonstruetlm, hretalldion for wbang, phmbtne, en hatlae, ewer or wrier. Be wre to as the Building hupsetor for sopor.% psrmha for thea bmw APPLICATION FOR BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S NAME, d:3 � � �- BUILDER -�Z_ ADDRESS -6. ( ADDRESS LOCATION OF BUILDING NO. `� TREET j A -14 Pfa -4- S � � PART OF LOT LOT BLOCK ADDITION OR SUBDIVISION CORNER LOT INSIDE LOT SETBACK 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. DESCRIPTION OF BUILDING To be used as; �ront Depth Height Sq. Ft. Cu. Ft. Front Depth Height Sq. Ft. Cu. Ft. Type of Construction Estimated Cost To be completed_�— 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. DATE SIGNATURK (Schedule of Fee Costs can be found on the Reverse Side). !me 11 - A 4,1 AA SUBJECT PERMI" City of Fridley 42 19714 AT THE TOP OF THE TWINS BUILDING PERMIT _ r � RECEI • _____ COMMUNITY DEVELOPMENT DIV. may_- r PROTECTIVE INSPECTION SEC. 3Z0 iCITY HALL FRIDLEY 55432 NUMBER REV, DATE PAGE OF APPROVED BY ----/---f,`� L 612-571-3450 910-F15 10%13/88 JOB ADDRESS 521 Mississippi. Street N. E. 1 LEGAL LOT NO. BLOCK TRACTOR ADDITION SEE ATTACHED DESCR. 7 1 Rice Creek Terrace Plat 1 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Wallace Erlandson 521 Mississippi. Street N.E. 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Netko Brothers Roofing 3446 Russell Avenue North, Mpls., 55412 529-7397 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAILADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION X7 REPAIR ❑ MOVE ❑ REMOVE B DESCRIBE WORK Reroof Dwelling (19 Squares.) 8 CHANGEOFUSEFROM TO STIPULATIONS Roof can be 2nd layer but not 3rd. Install ridged galvanized valley On all new roofs or tear -offs and replacement roofs, State Code requires that 2 layers of 15 Ib. felt, Mopped together, be installed to a point 24 inches UP from exterior wall line, or the use of other approved underlayment membrane. SEPARATE PERMITS ARE REQUIRED 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 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 ISTALLS 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 $95Ql�� $�50 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT 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. PLAN CHECK FEE TOTALFEE $25.50 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE)_1WHEN PROPERLY LI ATED THIS IS YOUR PERMIT `BLDG INSP Z � h SIGNATURE OF OWNER I IF OWNER BUILDERI IDATEI NEW [ ] City of Fridley EEfective 5/1/88 ADDN [ ] R-1 AMID R-2 ALTER [ ] Wilding Permit Application Construction Address:ss; 1212; N E Legal Description: L0 �l 'g\o a- I IRIfUl - P katl Owner Name & Address: W cAka� r' cA,nc \ S a \ ('n► s s S k E Tel. # Oontractor : t� '� ;,fothsu5�4�� 124 Tel. # S a - -134 -7 Address: 50,10— Attach to this application, a Certificate of Survey of the lot, with the proposoed construction drawn on it to scale. DESCRIPPION OF IMPROVEMEM LIVING AREA: Length Width Height Sq. Ft. Width Height Sq. Ft. �)4a�; �• "y • �r. Cbrner Lot [ l Inside Lot [ l Ft. Yd Setback Type of Construction: 00 ) r Approx. Completion Date: M- T l Proposed Driveway Width If New Opening Is Desired: Sq. Ft. Side Yard Setbacks Estimated Cost: Alt. A Alt. B 5 #_ Wic= + 61 See Back Page HATE: Ib-��-�$ APPLICW: Tel. 5a (-?39 CITY USE OMY Permit ]Fee State Surcharge $g5a SAC aorge Driveway Escrow $ Park Flee 5 Sewer Main Charge 5 TOTAL tuol.ljri4jKm Free Schedule on Reverse Side $.50/$1,000 Valuation $550 per SAC Unit Alt. OAA or Alt. "B° Above Fee Determined by Engineering Agreement Necessary I ] Not Necessary [ ] CITY OF FRIDLEY Effective Date May 1, 1988 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES RATE SCHEDULE RESIDENTIAL RATE TOTAL Job Address Furnace Shell and Duct Work, Burner (Also replacement furnace) $ 20.00 Gas Piping $ 10.00 (piping needed with new furnace) Gas Range $ 10.00 Gas Dryer $ 10.00 * Air Conditioning (all sizes) jf $ 10.00 All Others/Repairs and Alterations 18 of Value of Appliance or Work COMMERCIAL/INDUSTRIAL 1% of Value of Appliance or Work State Surcharge TOTAL FEE Reinspection Fee ($15.00) Rough Insp. Date Final Insp. /,7— Date Approval for Permit MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00 PLUS $.50 STATE SURCHARGE *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. $ $ .50 Department of Buildings, 6431 University Ave. N.E., Fridley,. MN 55432 City of Fridley Tel. #571-3450 The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Cordes and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. KIND C Fridley, Minn. 19& USED AS TO BE COMPLETED ABOUT 0 a ci :0 ESTIMATED COST d' "s /C��•- VLDNEW BUILDING PERMIT NO. PERMIT NO. /Dr-Z2� ESCRIPTION OF FURNACE/BURNER HEATING or POWER PLANTS, Steam, Hot Water, Warm(Air- No. Trade Name /`Qom _ Size No. C45 -0c - q 'O K -w - Capacity Sq. Ft. EDA STUgHP Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR BTU HP Company Signed By Tel. No. Fill out back side for stack verification on replacement furnaces CHIM14EY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack; 1. Has been carefully examined Yes (�) No ( ) 2. Is free from rust or deterioration Yes ( ) No ( ) 3. Has no foreign objects lodged within Yes ( ) No ( ) 4. Is securely supported Yes ( ). No ( ) S. Meets all current Code requirements for size and total BTU connected Yes ( ) No ( ) 6. Has Total heating BTU's of All other BTU's TOTAL Remarks Company Signed By Da to SUBJECT .�' `)HERMIT NO. City of 24814 4 8 1 4 AT THE TOP OF THE TWINS BUILDING PERMIT ' Jr? £/ COMMUNITY DEVELOPMENT DIV. L PROTECTIVE INSPECTION SEC�� r � , NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 612-571-3450 910-F15 12/6/96 JOB ADDRESS 521 Mississippi Street NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 1 Rice Creek Terrace Plat 1 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Wallace Erlandson 521 Mississippi Street NE 571-1818 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Phalen Siding & Trim Inc 1528 Lincoln St Paul MN 55105 731-2092 6216 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 ❑ ADDITION ❑ ALTERATION X REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reside house & garage; install aluminum window trim 9 CHANGE OF USE FROM TO STIPULATIONS TYPE OF CONST. OCCUPANCY GROUP OCCUPANCYLOAD SEPARATE PERMITS ARE REOUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION ZONING SO. 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 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 GRANTING OF A PERMIT $4,750 $2.37 PERMIT FEE SAC CHARGE DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- Fire SC $4.75 STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. $99.75 PLAN CHECK FEE TOTAL FEE UA,a YAJJ �' License SC $5.00 $111.87 WHEN PROPERLY IDAT D THIS IS YOUR PERMIT I t TUREOFCONTRACTOR AUTHORIZEDAGENT iDATtl aft &I BLDG NSP SIGNATURE OF OWNER OF OWNER BUILDER! IDATEI NEW [ ] Effective 3/1/96 ADDN [ J CITY OF FRIDLEY ALTER (] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application �( ConstructionAddress: A ) /i%i5 s I SS /Pp 7 Legal Description: Owner Name & Address: R 6qNr,) 5 0�1/ Tel. # S 7/ -IVI S) Contractor: ?1",44,5A) S:, p /A J ' MN LICENSE # _,;`2 l G Address: c„maco 4_ ,J �� /�r4 L Tel. # % aoj,?_ Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF IMPROVEMENT LIVING AREA,: Length_ Width ---� Height Sq. Ft. -GARAGE AREA: Length 'Width � .Height' Sq. DECK AREA: :Length Width Hgt/Ground Sq. Ft. OTHER: _ ;Fes, 110a.56 tLA R1a GE X1_1,,17�/,'» �o � � /� , ► Corner Lot [ ] Inside Lot [ ] Ft.' Yd Setback r, 'P,` Side Yard Setbacks Type of Construction: Estimated Cost: $ -el-7 Approx. Completion Date: (Cosh on Back) Driveway Curb Cut Width Needed: ' Ft. + 6 Ft = Ft x $ _ $ DATE: 6 APPLICANT: Tel. # S - ,P 0 G a b Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: CITY USE ONLY $ q9,%— Fee Schedule on Reverse Side $ - 'Y .001 of Permit Valuation (1/10th%) $ J.39 $.50/$1,000 Valuation $ $900 per SAC Unit $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above $450.00 Conservation Plan Review Fee Determined by Engineering Agreement Necessary [ ] Not .Necessary [ ] SUBJECT PER City of Fridley 6877 AT THE TOP OF THE TWINS BUILDING PERMIT ECEIP COMMUNITY DEVELOPMENT DIV. r PROTECTIVE INSPECTION SEC. 6 NUMBERREV DATE PAGE OF APPROVED BY i w �•� CITY HALL FRIDLEY 55432 ��"' _--- l J` 612-571-3450 910415 7129198 JOB ADDRESS 521 Missi sippi St 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 7 1 1 Rice Creek Terrace Plat 1 SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Elenor Erlandson 521 Miss. St427-5423 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO ' Owner 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 ❑ ADDITION O ALTERATION REPAIR ❑ MOVE O REMOVE 8 DESCRIBE WORK Reroof house and garage 28 S Tear-off CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with State Building Code. 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 1 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 2335 $1.16 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. $74.75 Fire S PLAN CHECK FEE TOTAL FE 24 S190AVdIiEOFCONTRA OR AU ORIZEDAG (DATEI HE PROPE GCCFG INSP Y LID ATED T S YOUR PERMIT ryA E SIGNATURE OF OWNERIIF OWNER BUILDER) IOATEI Aj NEW [ ] 1-019 � ` / � Effective 1/1/98 ADDN [ J CITY OF FRIDLEY %�' ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R -Z ✓�� �� BUILDING PERMIT APPLICATION ConstructionAddress: 6T Q Legal Description: Owner Name &'Z W. Contractor: 9/2 Tel. # MN LICENSE # Address: Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EIAPROVEMENT LIVING AREA: Length GARAGE AREA: Length DECK AREA: Lahngh OTHER: Construction Type: Width Height Width Height Width Hgt/Ground i Estimated Cost: $ Sq. Ft. Sq. Ft. _ Sq. Ft. 3S 4 '(Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: �`� 7 APPLICANT: 5l�l��y�Tel. # STIPULATIONS: CITY USE ONLY Permit Fee $ �, S� Fee Schedule on Reverse Side Fire Surcharge $ -3-3 .001 of Permit Valuation (1/10th%) State Surcharge $ Ze� $.50/$1,000 Valuation SAC Charge $ $1000 per SAC Unit License Surcharge $ $5.00 (State Licensed Residential Contractors) Driveway Escrow $ Alt. "A" or Alt. "B" Above Erosion Control $ $450.00 Conservation Plan Review Park Fee $ Fee Determined by Engineering Sewer Main Charge $ Agreement Necessary [ ] Not Necessary [ ] TOTAL $ / 9 -�-2 7 STIPULATIONS: O&V CZ41 W dmz) 4,-a,R "ll a HE -01434-04 8198 R MINNEs(YrA DEPARTMENT OF HEALTH Minnesota Well and Boring WELL OR BORING LOCATION o. WELL AND BORING SEALING RECORD MinnesoSealing ta Unique No. H (� 151034 County Name Anoka Minnesota Statutes, Chapter 1031: or W -series No. (Leave blank it not known) Township Name Township No.Range No. Section No. Fraction (sm. i Ig.) Date Sealed Date Well or Boring Constructed F;r i d l e 30 24 t 14 % N N I 5-5-99 Numerical Street Address or Fire Number and City of Well or Boring Location 5 21 i s.s p� i F r l d l @y Depth Before Sealing ft. Original Depth R. _Miss Show exact location of well or boring Sketch map of well or baring/,QUIFER(S) STATIC WATER LEVEL in section grid with 'X'. location, showing property lines, roads, and buildings. N G• -a- Yy -T- -- --T- -_ '__ �— W"+ E Single Aquifer ❑ Multiaquifer qWELUpppgrG [FWater Supply Well ❑ Monit. Well ❑ Env. Bore Hole ❑ Other Measured ❑Estimated ft. lf&low ❑ above land surface CASING TYPE(S) - - - !-- -i-- - -- �ouse -- - -i-- -i-- -i - t ,a S r mxe � Steel ❑ Plastic ❑ Tile ❑ Other CASING Diammeter Depth Set in oversize hole? Annualar space initially grouted? J 77 in. from to ft. ❑Yes JVNo ❑Yes ❑ No ❑Unknown in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown PRTT9RY8FFI'Sr11AM%.rl andso ooh JJ� GGit ethane in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown Prepedy amerffsllddm different well location address indicated above. Samna SCREENIOPEN HHOLE 1 Screen from 77 to 81 ft. Open Hole from to ft. OBSTRUCTIONS f3 Rods(Drop Pipe -t Check Valve(S) ❑ Debris ❑ FRI ❑ No Obstruction WELL OWNERS NAME T � � � ��� � � � � - • 'P 402 � H � 'e � a' ype of Obstructions (Desc�rirbte") X WW�V j Wen owner's meting address H different than property owner's address indicated above. Obstructions removed? L7 -res ❑ No Describe PUMP D -W jet HARDNESS OF GEOLOGICAL MATERIAL COLOR FORMATION FROM TO 3gT��ype CS Removed [I NotPresent ❑ Other if not brown, Indicate estimated formation log from nearby well or boring. M OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: No Annular Space Exists ❑ Annular space grouted with tremie pipe r ❑ Casing Perforation/Removal In. from to ft. ❑ Perforated ❑ Removed In. from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERUU-(S) i"�t Colt 5I 8 � 2 3/4 Grouting Material from to ft. yards bags from to ft. yards bags from to ft. yards bags from to fL yards bags REMARKS, SOURCE OF DATA, DIFFICULTIES M SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑ Yes ff No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The Information contained in this report is true to the beat of my knowledge. Mork Well Co., Inc. 02653 Co r mess Name License or Repbtrallon I'1o. Aut cifiz resenf five Signature Date Ron Danielson �QGFiI.C�NY H,148034 Name of Person Sealing well or eodng HE -01434-04 8198 R