PRE 2010 DOCSC�
City of Fridley, Minn.
BUILDING PERMIT
Date: June 12, 1969
Owner: Russel Gordon Builder
J. W. Lindquist Co.
Address 4.642 3rd St. N. E. Address 3500 Garfield Ave. S.
LOCATION OF BUILDING
No. - 4642 Street _mrd St. N. E. Part of Lot
Lot 3 __ Block 10 Addition or Sub -Division — Plymouth Addn .
Corner Lot --- Inside Lot — Setback --- Sideyard
Sewer Elevation
Foundation Elevation
N° 10281
DESCRIPTION OF BUILDING
To be Used as:
Garage Addn . Front 22 Depth 101 Height 81 Sq. Ft. 220 Cu. Ft.
Front Depth ____ Height Sq. Ft. Cu. Ft.
Type of Construction Frame Est. Cost _ 00.00 _ To be Completed
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 comp ce all provisions of
ordinances of the city of Fridley. 1
In consideration of the payment of a fee of $ 5.00 permit is hereby granted to J • W. Lindquist Co.
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 regarding location, construction, alteration, maintenance, repair and moving of buildin—e
within the city limits and this permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
Henry` F. Muhich
• Nona: If
This permit does not cover the construction, installation for whing, plumbing, gas heating, ewer or water. Bo euro to we
the Building Inspector for separate permits for these items.
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
OWm IS NAME,P.2G(�,�X gC� BUILDER •firs ��
ADDRESS Lf �- ,z "```S 7-1f rADDRESS 9—s-aU
LOCATION OF BUILDING
NO. STREET (p L{ 2& Ac S'T /d -P F ,
LOT ^ .- � BLOCK 16 ADDITION OR SUBDIVISION
CORNER LOT INSIDE LOT SETBACK SIDEYARD
SEWER ELEVATION TOP OF FOOTING
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
Depth 1,4 Height
d
Square feet Cubic Feet
Front
Depth Height
Square feet Cubic Feet
Type of Construction Tc . ,Estimated Cost 6� 2
A
To Be C
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 /, — / -7 SIGNATURE E_1. A
(Schedule of Fee Costs can be found on the Reverse Side.)
WPM
SUBJECT
PERM12451
City of Fridley
AT THE TOP OF THE TWINS
BUILDING PERMIT°
r
�
RECEIPT NO.
• COMMUNITY DEVELOPMENT DIV.
mss.-------�
INSPECTION
�,g�
r PROTECTIVE SEC.
1
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
/--->t CITY HALL FRIDLEY 55432
IL
L----� 612-660-3450
910-F15
3/7/74
JOB ADDRESS 4642 - 3rd Street N.E.
1 LEGAL
LOT NO.
CT OR ADDITION SEE ATTACHED
TRAPlymouth
DESCR.
3, pt. 4
TBLOCK
lO
Addition SHEET
2 PROPERTY OWNER MAILADDRESS ZIP PHONE
Florence Gordon 4642 - 3rd Street N.E.
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
North Central Builders 7401 - 42nd Avenue North
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 M ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE
B DESCRIBE WORK Reroof Structure
9 CHANGE OF USE FROM TO
STIPULATIONS -'If more than two roofs, remove one of them.
SEPERATE PERMITS REQUIRED FOR WIRING,
HEATING, PLUMBING AND SIGNS.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
Asphalt
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
R-1
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
860.00
.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 FORMANCE OF CONSTRUCTION.
$6.00
PLAN CHECK FEE
TOTALFEE
7
L,$6.5p
SIG TUREOFCO'N-TR_A-CTOR`ORAUTHORIZEDAGENT (DATE)
WHEN PROPERLY VALIDKIIEDTIS S YOUR PERMIT
BLDG INSP OA7E
SIGNATURE OF OWNER IIF OWNER BUILDER) (DATE)
APPLIC'ATION FOR RLSIDENTIAL, ALTERATION,
OR ADDITION BUILDING PERMIT
CITY OF I-IZI DLLY, MINNESOTA
OWNER'S NAME : -r o
reoucy
BUILDER: lyor:-14
nc�!.4J%r2, 1
Jet 1c-ey-5
ADDRESS:- i4� 4(2-
.3'j ST Nj�
ADDRESS:
A/o
NO:. i 6q-�-- STREET: 4 S/
LOT: BLOCK: ADDITION:
CORNER LOT: INSIDE LOT: 11-/ SETBACK: SIDEYARD:
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:
Square Feet:
Depth: Height:
Cubic Feet:
Front: Depth: Height:
Square Feet; Cubic Feet:
Type of Construction: /J'py-oo t- Estimated Cost: $ 7/0 O 1U
To Be Completed: -3 19 7 �
The undersigned hereby makes application for a permit for the work herein
specified, agreeing to do all work in stticL accordance with the City of
Fridley Ordinances and rulings of the Department of Buildings, and hereby
declares that i11 the facts and representations stated in this application
are true and corr,-CL.
DATE: 3-9-74 S [(;NATURE:
(See Reverse Side For Additional Information.)
� o
CITY OF FRIDLEY
APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION, REFRIGERATION AND
AIR CONDITIONING SYSTEMS AND DEVICES '
PARTIAL RATE SCHEDULE
GRAVITY WARM AIR:
Furnace Shell & Duct Work
*Replacement of Furnace
Repairs s Alterations -up to $500.00
Pepa'rs & Alterations each add. $500.00
:MECHANICAL I:AR:•i AIR:
Furnace Shell &. Duct Work to 100,000 BTU
each ad!.. 50,000 BTU'
*?aplacr.wert of Furnace
Repairs & Alterations -up to $500.00
Repairs & alterations each add. $500.00
S—, z,% I G? HOT i TATER SYSTBI :
Boiler & 1 -Ines up to 100,000 BTU
each adder. 50,000 BTU
Boiler Gnly up to 100,000 BTU
each addn. 50,000 BTU
OIL BUR` EI.- to 3 gal. per hour
each add. 3 gal. per hour
GAS BUR\EK- frca 100,000 BTU to 199,999 BTU
(over 199,999 BTU see Fee Schedule)
GAS FITTI\G FEES:
RATE
$12.00
7.00
7.00
4.00
$12.00
4.00
7.00
7.00
4.00
$17..00
4.00
7.00
5.00
$10.00
10:00
$10.00
1st .3 Fixtures X $ 3.00
Additional Fixtures x $ 1.00
Gas Range to 199,000 BTU x $10.00
ATCONDITIONING
:=AN HEATING SYSTEMS See Fee Schedule
VZN ILATING SYSTEMS
ALtER:ATIONS & rEPAIRS
State Surcharge •
TOTAL FEE
ROUGH T -NSP.
Date
FETAL IPSP. / 2 -11-fl
Date
AP2ROVAL FOR: PERMIT /
REINSPECTION FEE .r
010.00)
TOTAL
S
S
NZ -=%UM FEE FOR ANY HEATING PERMIT IS $7.50 PLUS $.50 STATE SURCHARGE
rAttached stack verification form
WA
Job Address
Department of Buildings
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 Codes -
and rulings of the Department of Buildings, and hereby declares that all the
facts and representations stated in this application are,true and correct.
• (�F4id_lenQy, Minn. 19.F/
OWNER
KIND OF BUILDING
USED AS
TO BE COMPLETED ABOUT V�
Oa _
ESTIMATED COST
COLD
- NEW BUILDING PERMIT NO. PERMIT NO.1��
DESCRIPTION OF FUTVACE/BURNER
HEATING or POWER PLANTS, Steam, Hot Wate Warm A No.
Trade Name Size No. L�%l6Aer
Capacity Sq. Ft. EDR BTU HP
Total Connected Load Kind of Fuel
BURNER - Trade Name Size No.
a
Capacity Sq. Ft. EDR --2 BTU HP
e _ Company
car -ems Signed By 0
Tel. No. �S 333
�li p�'rJ u,
City of Fridley
SUBJECT
20299
AT THE TOP OF THE TWINS
BUILDING
PERMIT
_
r?
1
RE
• COMMUNITY DEVELOPMENT DIV.
r i PROTECTIVE INSPECTION SEC.
1 = �
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
L J\� 612-571-3450
910-F15
4/13/90
JOB ADDRESS 4642 ¢ 3rd Street N.E.
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
DESCR.
3, pt, 4
10
Plymouth_ Addition SHEET
2 PROPERTY OWNER MAIL ADDRESS
ZIP PHONE
Judy Gordon 4642 - 3rd Street N,E,
572--8852
3 CONTRACTOR MAIL ADDRESS
ZIP PHONE LICENSE NO.
Murray Hermanson Const, 16724 Washington Street Ham Lake MN 55304 434-4620
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 ❑ REPAIR ❑ MOVE ❑ REMOVE
X
8 DESCRIBE WORK
Construct a 29A x 15'1' Addition to DWelling
and Reside
9 CHANGE OF USE FROM
TO
STIPULATIONS
See notations on plan,
WA
Before
SEPA RA ��
gn
an utility locations 0
%�,� �_j
h&q�` p kclq
434-0002
Q��R��
�. 0t
Q jmaf�' ° FOR
B Y LAW
AND
S GALS
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
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
$24 250
$12,13
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$252.00 OR THE PERFORMANCE OF CONSTRUCTION.
P N CHECK FEE
TOTAL FEE
$264.13
SIGNAT EOFCONiRACTORORAUTHORIZEDAGENT ID TEI
WHEN PROPERLY VTED THIS IS YOUZERMIT
)NSP �
SIGNATURE OF OWNER IIF OWNER BUILDER) IDATEI IBLDG
NEW [ ]
ADDN [ ]
ALTS [ ]
,ate,!'=1 t,ti •;, ; . 7-77-7 IT
legal Description:
CITY OF FRIDLEY
R-1 AND R-2
Building Permit Application
Effective 1/1/90
Owner Name & Address: � u Q �N 0 '0
Contractor: `tMv\q Q- t. Tel.
Address: \ `� y w �v �T tel sT . �'�°�'� --P'�e �5 5 3 0
Attach to this application, a Certificate of Survey of the
lot, with the prgPosed construction drawn on it to scale.
D£SCR=OK OF
UMM AREA: Length a z1' Width 1 c5-- Height \ Sq. Ft. S
GNU= AREA: Length Width Height sq. Ft.
DDCR AREA: Length Width Hgt/Grouxl Sq. Ft.
07HM (dX)b)
Corner Lot [ ] Inside Lot [X] Ft. Yd Setback ,b ) Side Yard Setbacks \\
- of Construction: '\,"3 Estimated Cost: $ aL-\ , a
�rox . Completion Date: \\ .
Proposed Driveway Width If New Opening Is Desired: Ft. $ $
Width + 6' See Back Page
DATE: \2 '� APPISCANI'
Tel. # '--\ �\
Permit Fee $ n Q00
State Surcharge $
SAC Charge $
Driveway Escrow $
Park Fee $
Sewer Main Charge $
70M .
it J3
:
CITY USE ONLY
Fee Schedule on Reverse Side
$.50/$1,000 Valuation -
$600 per SAC Unit
Alt. "A" or Alt. "B" Above
Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
'AGREEMENT
<— owner of the property located
at ^y 3� 3R��.� Nhave no objection to the City
allowing the construction of,-m/an
to be located at Y4 41,� - .3j4,� & t , , without the
required certificate of survey that the City ordinarily requires for all new
construction.
r
a,
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om
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3,
wA
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GI
HERMANSON ,
Dodos tit MW bunt HOMOS
Witid - becks - Garages - AddIlloha;. Ne* Homes
complete Hemodeling
W70v
As- 03
box \2* 30
.434-4620
I
Ei
f
S/
yGya— 3 s N�
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0
.26/
R' �e O
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SZZUAV Y
A--rA- 3
$�
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yGya— 3 s N�
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0
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R' �e O
OS , / e
SZZUAV Y
A--rA- 3
f
HERMANSON
BUIldefS di Mlef built HOMeS
t1dirig - becks - Garages - Additions New Homes
Complete rlemodeling
kAb
A, j 0 4Q64 it Q
-V0.%kssles .2tk"o-C,
I %I
1 434-4620
T-
1\\ "
R. S*,ve"r ter -K
yx I
gout,%%
V.& M43%%W
AwA-0. Swifatmi
q 04 sub"lid,
W; q tc- ;- \ t4 \ S 'A E lb C) AK 'r -1.0o v 9444 v a 0-
3o, 'T. Ca RL\kwoot). -.%A% kokkf-97 ALSO
4
$c -S. lee, C, #,A Uj I -
vi Dow) 2 Lk#1
3 NC- f" I
klkat% %MQ\VMl *
IE x C. f, \JN -T E b
1.,�C-Oopse
**COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6—A. MINIMUM SIZE 9 SQ INCHES.
fa
GORDON, JUDY MARIE
4642 3RD STREET NORTHEAST
PLUMBING FIXTURE RATES: NO.
RATE TOTAL
JOB ADDRESS_ FRIDLEY, MN 55421
(612)572-8852
New Fixtures
$ 7.00
The undersigned a work herein
Old Opening, New Fixture
$ 4.00
specified agreeing to do all work in strict accordance with the city codes
Beer Dispenser
$ 5.00
and rulings of the Building Division, and hereby declares that all the facts
Blow Off Basin
$ 7.00
and representations stated in this application are true and correct.
Catch Basin
$ 7.00
Cj
Rain Water Leader
$ 7.00
Sump/Receiving Tank
$ 7.00
Water Treating Appliance
$10.00
Owner
Water Heater —Electric
$ 7.00
Water Heater — Gas** _�
$10.00
Building Used As
Gas Range**
$10.00
C
Gas Dryer**
$10.00
��
Estimated Cost PERMIT NO. �1
Back Flow Preventer Required ( )Yes (} No
® ��n
095LZM &rqAJIJ
Type
$15.00
PLUMBING COMPANY
Reinspection Fee $42.00/Hr
SIGNED BY TEL N0.
ALL OTHERS AND/OR REPAIRS AND ALTERATIONS
MvZ�
1.5% of Value of Fixture or Appliance
Approved By Rough—In Date Final Date Ar / oc
State Surcharge
$ .50
MINIMUM FEE FOR ANY PLUMBING/GAS PERMIT IS $20.00
TOTAL FEE
$20.C;D
PLUS THE $.50 STATE SURCHARGE
**COMBUSTION AIR SHALL BE PROVIDED PER UMC SECTION 504(A) AND TABLE 6—A. MINIMUM SIZE 9 SQ INCHES.
fa
G7YOF
FRIDLEY
FRIDLEY MUNICIPAL CENTER - 6431 UNIVERSITY AVE. N.E. FRIDLEY, MN 55432 - (612) 571-3450 - FAX (612) 571-1287
September 18, 2000
Judy Marie Gordon
4642 3 Street NE
Fridley, MN 55421
Re:Final Inspection at 4642 3 Street NE
Contractor: Norblom Plumbing Co.
Dear Ms. Gordon:
A plumbing permit was issued on June 29, 1999, for the above noted address,
to install a gas water heater. According to section 4715.2800 of the State
Plumbing Code, a final inspection shall be conducted on the plumbing authorized
by this permit. As of this date no inspection has been called for.
You will be given thirty (30) days from receipt of this notice to respond. If we do
not hear from you, we will expire the permit and any inspections on this
installation will require a new permit.
Any questions can be addressed to myself at (763) 572-3603.
Sincerely,
BuildiN Inspector
CITY OF FRIDLEY INSPECTION DIVISION
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
(763) 572.3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
RATE SCHEDULE
Resldeniial
Furnace Shelf and Duct Work, Burner -
Also Replacement Furnace
(Side Vent - Fill Out Hack)
Gas Piping (Needed with new furnace,
but not replac ennent)
Gas Range
Gas Dryer
'Air Conditioning - All Sizes
All Others/Repairs & Alterations (LIST ON BACK)
1% of Value of Appliance or Work
Cmnmercialllndustrial
1.25% of Value of Appliance or Work
Rate
$ 30.00
$ 10.00
$ 10.00
$ 10.00
$ 25.00
State Surcharge
TOTAL FEE
MIMIIlflUllfl FEE FOR ANY HEA71MG/IOOIAN iWENMLA11ON
REFIRIVIERATIMMR CONDITIONING PERMIT IS 925
EMS E $.50 STATE SURCHARt`E
REINSPECTION FEE $47.00/Hr
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner.
TOTAL
$ 30.00
$
$
' I
$ 456•51?
"
Effective On January 1,2002
JOB ADDRESS LF6Lt2, 510D ✓Ti2E2E7 l4C
OWNER JW'J _-- Golgi-pebf
BUILDING USED AS PE& Do%iCj[�E
ESTIMATED COST 4; 3 2a. 00 PERMIT NO.
�CRIPTION OF FURNM AND OR BURidER
No. of Heating Units l . Circle One (Steam) (Hat Water} )
Trade Name V� Size No. 6P 07 1`2
BTU ?0 4,0CP0 HP EDFR
FuelW&T . 6R -S Total Connected Load
Burner Trade Name Size No.
BTU HP EDR
u
#A'
31
3
0
-4
{
9
d
r
m
{
The undersigned hereby makes application for a permit for the work herein
specifed agreeing to do all work in strict accordance vft the City Codes an
rulings of the Building Division, and hereby declares that all the facts and
representations stated in this application are true and correct. O
DATE �L
HEATING CO � MA.4 012650 I/- ZA �
Signed TEL 0
FAX # W7 -7.
Approved 13y Rough -4n Date Final Date (6 6 4 L
SLIT BACK SIDE E STACK VERIFICATION ONREPLACEME-NTT FURNACE
211
THE BELOW MUST BE FILLED IN MM REPLACING FUEL BURNIPIG APPLIANCES OR THE
APPLICATION WILL BE RETURNED
,COMMON AWL UeNT_ NN CTOR ANn CQM1811STI ON AIR VVERIETION
When mplacing an awlafina ftmwa the undersigned hereby verifies that the
venting has been examined and is free from rust, deterioration, obstructions,
and is securely supported and tirestopped where required. Yes { No( )
The venting system is plastic/PVC and meets all current codes and manufacturer
specifications Including sizing, length, number of elbows and termination. Yes { No ( )
The undersigned also verifies that the replacement unit is a listed assembly
and meets the current codes and manufacturers lspeclflaWons. This does
Include AGA-GAMA Category I Central Furnace Venting Tables for fan
assisted and natural draft appliances. Yes ()o No ( )
TheY;�. tsd 4 a�ro�+• •ellen �Ir is shed and Installed to meet the currant codes
and manufacturer's specificcations. Yes 00 No ( }
When required to infill a nawee;,Mbi len=lr. it will be sized end instilled
to meet the current codes and manufacturers specifications. Yes 0 No ( )
When InMNIng a nmu wanhing wMam, the undersigned hereby v011e8 that
c •
it is a listed assembly and meets the current codes and manufacturer's
specifications. This does Include AGA LAMA Category I Central Furnace
Venting Tables for fan assisted and natural draft appliances.
Yes Qq No( }
Is the common vent and vent connectors sized and installed correctly atter
an appliance has been removed from the common vent and vented
Yes "No ( )
separately as per current codes.
'frena► Abe!C-mmea V/nn end Vents [ knt
Information
Appllanm and Q0n
Appliance 0l Type I✓V2njAt,,�; BTU Input -W. n+o o Fan Assisted or Nat,�„�
Appliance #2 Types dd= Wit BTU Input � _ooc Fan Assisted or Not
Appliance #3 Type BTU Input Fen Assisted or Net
Total Appliances ® Z Total Stu input
Common Vent Type Vent Height ` [meter_______
Inches
Appliance #9 Vent Connector Height,___ ft Length _ft Diameter
In Type
Appliance #2 Vent Connector Height ft Length Diameter
in Type
Appliance #3 Vent ConnecW Height ft Length ____ ft Dlameter„_-Jn
Type
MUM
r
b0iz0' d L1?Lb9£91 S9 01 A-=na I mzi d0 Ja I0 WONJ S£ : £ti z00z-bti-a3j
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH, Minnesota Well and Boring H'
Sealing No. 292593
-WELL AND BORING SEALING RECORD Well No.
County Name Minnesota Unique
or W-§edes No.
Anoka Minnesota Statutes, Chapter 1031 (L— Kank 9 11,-)
Township Name
To—ship No.
Range No.
Section No.Fraction (sm. - Ig.)
Date Seated
04/6/11
Date Well or Boring Constructed
Unknown
Fridley
30
24 II 111
26 �NE, W,/S
W
45 03 1.50
27
27
minutes ds
GPS Latitude degreeI utse rids
LOCATION: Longitude_ d iC'ds
Depth Before Sealing ft.
Original Depth —ft.
FER(S)
STATIC WATER LEVEL
minutes_
egr:!� nut
Numerical Street Address or Fire Number and City of Well . or Boring Location
Ingle Aquifer 0 Multiacluffer
ensured 71 Estimated Date Measured 04/6/11
WELUBORING
4642-3'rd St Fridley MN �5421
10.
map
Show exact location of well or boring Sketch lir 1
m pot
*ater-Supply Well 0 Monft. Well
20
jocaff. Erty
in section grid with 'X.- n,
Env. Bore Hole El Other
III ow El above land surface
CASING TYPE(S)
PUMP
.T 1
N lines, roads, SM 1111dings.
EML Momm
a
E] Other
Era] E] Plastic ❑[] Tile E] Other
WELLHEAD COMPLETION
E Tt
PR0ffF&fW0NEfj IN ElVVYrN
CASING(S)
Outside: E] Well House F1 At Grade Inside: 0-ament Offset
Well Pit
1h milePilless
Property owner's mailing address R different than wel[focafflon address Indicated above
If V,
Adapter/Unft 0 Burled
E3 Buried
❑ well Pit
a
E] Other
Other
PR0ffF&fW0NEfj IN ElVVYrN
CASING(S)
S e 12 0
y on
DIam(2r Depth Set In oversize hole? Annular space ally grouted?
in. from 0 to 24
❑Yes [I Yes I& El unknown
Property owner's mailing address R different than wel[focafflon address Indicated above
6710 — 37Th Ave
—ft.
Crystal, MN 55427
In. fromtqft. E] Yes [I No 0 Yes El No C3 Unknown
In. from tck— it. 7] Yes [] No El Yes 0 No E) Unknown
WELL OWNER'S NAME/COMPANY NAME
SCREENJOPEN HOLE
24 27
Well owner's mailing address R different than property owner's address Indicated above
Screen from— to�_��ft. Open Hole from kII—ft.
OrTUCTIONS
s/Drop Pipe El Check Valve(s) El Debris El Fill El No Obstruction
LV
Pipe & Jet
Type of Obstructions (Describe)
GEOLOGICAL MATERIAL
COLOR
HARDNESS ORFROM
FORMATION
To
Obstructions removed? N4,% El No Describe
If not known, Indicate estimated formation log from nearby well or boring.
PUMP
Sand Brown
0
11
El Removed of Present ❑ Other
Gravel Brown
11
14
OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
Clay Gray
14
60[ro
Annular Space Exists ❑ Annular Space Grouted with Tremle Pipe E] Casing Perforation/Removal
In. from to ft. D Perforated 0 Removed
Gravel Dark
60
70
Fine Sand Brown
70
95
In. from t ft. ❑Perforated El Removed
Gravel Dark
95
105
Type of Perforator
Platteville lime
105
111
E] Other
l I�
St. Peter Sandsone
Ill
14 0
GROUTING MATERIAL(S) (One bag of cement 94 lbs., one bag of bentonite = 50 lbs.)
Neat Grout 0 27 .5
I 1� � I
Grouting Material from to _ _ ftyards bags
I. -r -m -
it�
ETM
from to ft_ yards bags
S,
WINte ReRt
lati
ons
from toft_ yards bags
11
IOTHER
WELLS AND BORINGS
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
Other unsealed and unused well or boring on property? El Yes N 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
Geology From: 4849 University Ave
Is true to the best of my knowledge.
Water Level in Above Well: 34'
E.H. Renner & Sons, Inc. 1431
Date Water Level Takeni 05/12/1946
Licensee Business Name License or Registration No.
Nearby Well
4/19/11
Unique 206693
Certified Representative SRjn1TuF"ft4I 1111I 0.)A*.4,gZ:Zd Rep. No. Date
Tony Eisinger
LOCAL COPY
H
I 29"2593
!
Name of Person Sealing Well or Boring
HE -01434-12 IC# 140-0423
9109R