PRE 2010 DOCSCity of Fridley, -Minn.
BUELDING PERMIT N® 3570
Date . � ...... �............... .
Owner ....................................... Builder ................... Cf. . XK.....
Address...................................... Address .............................................
LOCATION OF BUILDING
No. lffA f .. Street ..... ... . ...................... Part oplot ...............................
Lot ..S ..... Block ..... .......... Addition or Sub -Division ...... .. P%4111 l......... .
Corner Lot ............ Inside Lot Y ......... Setback —. Sideyard ../® - ..........
DESCRIPTION OF BUILDING
To be Used as: t "
. ........
Front ®�®Depth 07&.21KHeigt / —.a
PSq. Ft. �®.0A Cu. Fg./.
7
.................... Front ........ Depth ........ Heightt.
........ Sq. F........ Cu. Ft.........
Type of Construction ................... Bit. Cofl--' .4`` ....... To be Completed
In consideration of the issuance to me of a permit to construct the building desribe above, I agree to do
the proposed work in accordance with the description above set fopand compli all ovisions of
ordinances of the city of Fridley.
.X ................. . .. .........
In consideration of the payment of a fee of $.V........ permit is hereby granted to ...................
......................... 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 buildings with-
in the city limits and this permit may be revoked at any three upon violation of any of the provisions of said
ordinances.
- .41, �- c�.... B ding Inspector
NOTICE:
This permit does not cover the construction, Installation or alteration for wiring, plumbing, gas heating,
sewer or water. Be sure to see the Building Inspector for separate permits for these items.
City of Fridley, Minn..
BUILDING PERMIT N®4 6 2 2
Date: "°""_.. I..._._.._._.._._.. _ _ .._.._._..._..
it
Owner:. ' 4 �Builder`
Address ...0 ., _..�� Address
LO/CATIQN OF BUILDING
No. J~ _Street...._ ............._......._.._- Part off Lot .......
Lot ._1�-._...._.-...... Block ................... Addition or Sub -Division
CornerLot ....._ ...................__...... Inside Lot .................... .................. Setback ..... ............. ..................... _. Sideyard _..._..._....................
Sewer Elevation ....... Foundation Elevation
DESCRIPTION OF BUILDING
To be Used
.,as:
dl�j { / /
� _.. 'rcSf!.A_..__... Front-�..--- Depth ...a .,��...•_+: Height ., .......... Sq. Ft. _(G? _. CU. Ft. G b-�
....
...............
..............
.......
-- .............. k'ront .............. ....... Depth ....-......., H ght ............ sq. Ft......_..-----•-••--- Cu. Ft. ----- -------------
._..
Type of Construction .:C.. --f .. Est. Calf/If . p .jl.. ............ To be Completed ............... ..................................
CAUTION
THIS PERNiff DOES NOT AUTHORIZE VIOLAT.
IOC'
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 provisions of
ordinances of the city of Fridley. Jr
In consideration of the payment of a fee of $. ----, permit is hereby granted to. .... _............................................ ..._..
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 buildings
within the city limits and this permit may be revoked at any time upon violation -of any of the provisions of said
ordinances. A �'i 1
Building Inspector
NOTICE:
This permit does not cover the construction, installation for wiring, plumbing, gas heating, sewer or water. Be sure to see
the Building Inspector for separate permits for these Hems.
4
APPLICATION FOR BUILDING PERMIT
CITY OF FRIDLEY, MINNESOTA
Owners Name LD Jp 3'®l,��Y� Builder C-! rY Ed&,4 r E � A
Address 9 _5-Z0-5 _ Address ,&,K. L - T 1VZA:A4_,
LOCATION OF
No.Street _ Part of Lot_,,,�_„�,
Lot , Block ,f Addition or Sub.Div.
Corner LotInside Lot Set Back Side -Yard
SEWER ELEVATION FOUNDATION ELEVATION
Applicant attach to this form Certificate of Survey, of Lot and proposed building
location.
DESCRIPTION OF BUILDING
To be used as:
�,4 C If F b C'48" Front Depth_ • Height ��
Sq. Ft. f /.6 Cu. Ft. j,2.,6�_
III? I _ Front -22_„ Depth Height
Sq. Ft. Cu. Ft,
Type of Construction /l�"P� - Estimated Cost 1y,®r___
To be
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work in strict accordance with the City Ordinances and ruling of
the Department of Buildings, and hereby declares that all the facts and representa-
tions stated'in this application are true and correct.
DATE 04z*,_ I._../,Vr't SIGNATURE
(A Schedule of Fee costs can be found on the Rever Side.)
City of Fridley, Minn.
BUILDING PERMIT
Date: _ June 9, 1965
Ron Johnson
Builder
McCall and Compang
Address 59Q2 5th Street N. E. Address 1618 W Lake Street
N? '7799
2S, Wyk'
LOCATION OF BUILDING
No. 5909. Street 5th Street N. E. Part of Lot
Lot 5 _ Block 1 Addition or Sub -Division Sennett Palmer
Corner Lot _ Inside Lot Setback Sideyard
Sewer Elevation ` Foundation Elevation
DESCRIPTION OF BUILDING
To be Used as:
Front Depth Height Sq. Ft. Cu. Ft.
Front Depth Height Sq. Ft. Cu. Ft.
Type of Construction Fst. Cost 8540,00 To be Completed
0 Storm damage repair
EA
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 anTInmpliance with a'll provisions of
ordinances of the city of Fridley.
In consideration of the payment of a fee of S 10.00 , permit is hereby granted tACCan and Co.
to construct the building or addition as described above. This permit is granted upon
the express condition that the peon 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 g location, construction, alteration, maintenance, repair and moving of buildings
within the dty ]iavitsnthis permit may be revoked at any time upon violation of any of the provisions of said
ordinances.
A,32en Jensen Building Inopector
NOTICE
%b perm& don at cmar tho Bond mcdon, hutaWan for whing, phmbine, Ba hadag, awa or wdor. Bo sora to we
&a Boildin l npodar for apmft porndu far thea bmw
APPLICATION FOR ING PERM
CITY OF FRnMO &NMSOTA
OWNER'S NAME RON JOHNSON BUILDER
ADDRESS 5909 - 5th St4 NE ADDRESSJ.�IiSR
LOCATION OF BtT1sMM
No., Street Part of
Lot, Block_Addit.ibnror Subdlvibionz 4'�"�
Corner Lot Inside Lot ,ySetbswtk Side -Yard
SEWER ELE`VATIQN FOUNDATION ELEVA`i"M _
Applicant attach to thi9 form Two Certificates of. Survey of Lot and propc3ssed" ''
ing location drAwn on these CA-ttificates.
Tia be used as:
DESCRIPTION OF BUILDING
Proal
—Depth, H-aight ... _._....�:
Sq. Ft. Cu. Ft.
Front Depth Height
Sq. Ft. Cu. Ft.
Type of Construction Estimated Cost $ 5000.00
The undersigned hereby makes application for a permit for the work herein specified,
agreeing to do all work art strict accordance with the City of Fridley Ordinances and
rulings of the Departna_-ai of Buildings, and hereby declares that all the facts and
representations stated in this application are true and correct.
_tSebedule,.of Fee Costs can be found on the Reverse Side).
Replace roof - siding. Glass, screens. Painting and general repair.
CITY OF FRIDLEY INSPECTION DIV.
Effective On January 1, 1991
6431 University Ave NE
Fridley, MN 55432 APPLICATION FOR POWER PLANTS AND HEATING, COOLING, VENTILATION,
572-3604 REFRIGERATION AND AIR CONDITIONING SYSTEMS AND DEVICES
JOB ADDRESS "��C) 1 S c -L Sd�Eg"
RATE SCHEDULE
The undersigned hereby makes application for a permit for the work
Residential Rate
TOTAL
herein specified agreeing to do all work in strict accordance with the
Furnace Shell and Duct Work, Burner -
city codes and ruling of the Building Division, and hereby declares
Also Replacement Furnace $ 20.00
$
that all the facts and representations stated in this application are
true and correct.�Z99t-
Gas Piping (Needed with new furnace) $10.00
$
OWNER, �` `OtA2Lt,_
Gas Range $ 10.00
$
BUILDING USED AS eQI-de_InC'0_
Gas Dryer $10.00
$
ESTIMATED COSTPERMIT NO.
*Air Conditioning - All Sizes $ 10.00
or.�-
$1®-
DESCRIPTION OF FURNACE AND OR BURNER
All Others/Repairs & Alterations (LIST ON BACK)
1 % of Value of Appliance or Work
$
No. of Heating Units ircle One (Steam) (Hot Wat a
Trade Name Size No. 2 4-o oN
Commercial/Industrial
BTU HP EDR
1 % of Value of Appliance or Work
$
Fuel Total Connected Load
State Surcharge
$ .50
Burner Trade Name Size No.
BTU HP - EDR
TOTAL FEE
MINIMUM FEE FOR ANY HEATING/COOLING/VENTILATION
REFRIGERATION/AIR CONDITIONING PERMIT IS $15.00
PLUS THE $.50 STATE SURCHARGE
REINSPECTION FEE $30.00
HEATING COM
Signed
Approved By Rough -In Date
Tel No. 7S--7/ ` 8/ 7 T'
Final Date �'- �/-�:Z
*Air Conditioners can not be placed in a side yard without
written permission from adjoining property owner. FILL OUT BACK SIDE FOR STACK VERIFICATION ON
REPLACEMENT FURNACE
CHIMNEY 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 ( i
4.
Is securely supported
Yes
( )
No ( )
5. Meets all current Code requirements for
size and total BTU's connected Yes ( ) No ( )
6. Has total heating BTU's of
All other BTU's
TOTAL BTU's
Remarks
List Alterations Being Done:
HEATING COMPANY
Signed By
Date
SUBJECT
P `t
City of Fridley
21927
AT THE TOP OF THE TWINS
BUILDING PERMIT
O.
COMMUNITY DEVELOPMENT DIV.
r PROTECTIVE INSPECTION SEC.
O
CITY HALL FRIDLEY 55432
NUMBER
REV.
DATE
PAGE OF
APPROVED BY
J 612-571-3450
910-F15
6/23/93
JOB ADDRESS 5909 5th Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION SEE ATTACHED
DESCR.
5
1
Bennett Palmer SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE
Scott Pladen 5909 5th Street NE
3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO.
Richard Hastings Roofing 6331 Riverview Terrace NE, Fridley 574-9966 4051
4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO.
5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO.
B USE OF BUILDING
Residential
7 CLASS OF WORK
❑ NEW ❑ ADDITION ❑ ALTERATION REPAIR ❑ MOVE ❑ REMOVE
8 DESCRIBE WORK
Reroof C22.Squares.l 2nd Layer
9 CHANGE OF USE FROM TO
STIPULATIONS
Roofinq can be the. 2nd layer but not tha 3rd. Provide adequate attic
ventilation, ice and water protection at eaves and valleys:. Install smoke detectors
as per UEC 1210. - adjacent to all sleeping areas and in basement.
TYPE OF CONST.
OCCUPANCY GROUP
OCCUPANCY LOAD
SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING,
VENTILATING OR AIR CONDITIONING.
ZONING
SQ. FT.
CU. FT.
THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION
AUTHORIZED IS NOT COMMENCED WITHIN 80 DAYS, OR IF CONSTRUCTION
OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 120 DAYS AT
NO. DWLG. UNITS
OFFSTREET PARKING
ANY TIME AFTER WORK IS COMMENCED.
I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION
1
STALLS GARAGES
VALUATION
SURTAX
AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS
AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
$1x188
$.59,
WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT
PERMIT FEE
SAC CHARGE
DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE
P OVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON-
$29.00
Fire SC $1.19
S RUCTION OR THE PERFORMANCE OF CONSTRUCTION.
PLAN CHECK FEE
TOTAL FEE
� ,,
�-�
L`€ 6 z 3 y'3
License SC $5.00
$35.78
SIGNATURE OF CONTRACTOR OR AUTH041ZED AGENT IDATEI
WH= PER ALIDATED THIS IS YOUR PERMIT
BLDG INSP GATE
SIGNATURE OF OWNER OF OWNER BUILDERI IDATEI
NEW j ] Effective 5/26/93
ADDN j ] CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND ' DUPLEXES R-1 AND R-2 --t� o
Building Permit Application
Construction Address: S'7&7 S7`.� s7`. W.
Legal Description:
Owner Name & Address: 5-
ca7`7" SAAer Tel. #
Contractor: K c X p -e j3 AAS 7`„./6 S MN LICENSE # 116 S/
Address: T'FK Tel. # S > Y- S 99'6
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF IWROVEMENT
LIVING AREA: Length Width
GARAGE AREA: Length
DECK AREA: Len
Height
Sq. Ft.
Width Height Sq. Ft.
Width Hgt/Ground Sq. Ft.
Corner Lot [ ] Inside Lot j ] Ft. Yd Setback Side Yard Setbacks
Type of Construction: KZ' 9 C b Estimated Cost: $ 1/4c
Approx. Completion Date:
�. Z S� • (Cost on Back)
Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $
DATE: ! ±3L-73 APPLICANT: r � .,� Tel. # 57
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
$ ..29. 00 Fee Schedule on Reverse Side
$ I �7 .001 of Permit Valuation (1110th%)
$ 2/ $.50/$1,000 Valuation
$ $750 per SAC Unit
$ 5 . CO $5.00 (State Licensed Residential Contractors)
$ Alt. "A” or Alt. "B" Above
$ Conservation Plan Review $450.00
$ Fee Determined by Engineering
Agreement Necessary [ ] Not Necessary [ ]
STIPULATIONS:
-
SuB.,ECT
MIT NO.
City of Fraley
2 9 45 0
AT THE TOP OF THE TWINS
BUILDING PERMIT
f
O•
►v ______ COMMUNITY DEVELOPMENT DIV.
SEC.
q
r PROTECTIVE INSPECTION
�
1 1 CITY HALL FRIDLEY 55432
�'�
NUMBER
REV
DATE
PAGE OF
APPROVED BY
612-571-3450
910415
5/12/99
JOB ADDRESS 5909 5 Street NE
1 LEGAL
LOT NO.
BLOCK
TRACT OR ADDITION
SEE ATTACHED
OESCR.
5
1
Bennett Palmer
SHEET
2 PROPERTY OWNER MAIL ADDRESS ZIP
PHONE
Scott Pladsen 5909 5 Street NE
571-8195
3 CONTRACTOR MAIL ADDRESS ZIP
PHONE LICENSE NO
Master Remodeling Inc 32 10 Ave S, Hopkins, MN 55343
932-9311 20012916
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
O NEW ❑ ADDITION O ALTERATION jJ REPAIR
O MOVE O REMOVE
8 DESCRIBE WORK
Reside House & Garage; Soffit & Fascia; Trim
9 CHANGE OF USE FROM TO
STIPULATIONS
Call for building wrap inspection before covering.
Install ventilation
in soffit to meet the State Building Code.
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
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 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
$8 080
$[F 04
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-
$167.25
Fir SC $8.08
STRUCTION OR THE PERFORMANCE OF CONSTRUCTION
PLAN CHECK FEETOT
FEE
Li C $5.0
$184.37
SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT IOATE,A
WIDAD2H�S IS YOURPERMIT 9SIGNATURE
HEN R PpA
OF OWNEPOF OWNER BUILDER, IDATEI
-8L ,NSP
TE
JUN -16-1998 11:39 FROM CITY OF FRIDLEY TO 9329316 P.01i02
NEW Effective I/1/98
ADDN [) CITY OF FRIDLEY
ALTER [ ] SINGLE FAMILY AND DUPLEXES R -X AND R-2 �n
BUILDING PERMIT APPLICATION
ConstructionAddress:
Legal Description:
Owner Name & F u -,Io&;A -ems Tel. # %/
Contractor: 32 M A b, MN LICENSE # 2 `)/ (o
Address: MN iiiiTel. # &/z
Attach to this application, a Certificate of Survey of the
lot, with the proposed construction drawn on it to scale.
DESCRIPTION OF EAFROVEM ENT
LIVING AREA: Length Width Height Sq. Ft.
GARAGE AREA: Length Width Height Sq. Ft.
DECK AREA: Length Width Hgt/Ground Sq. Ft.
OTHER:
Construction Type 1Gimated Cost. $d 4 �a • ®�C
(Fee Schedule on Back)
Driveway Curb Cut Width Needed: Ft. + 6 F -t = F $ _ $
DATE: 210_hkL APPLICANT: Tel. #
Permit Fee
Fire Surcharge
State Surcharge
SAC Charge
License Surcharge
Driveway Escrow
Erosion Control
Park Fee
Sewer Main Charge
TOTAL
STIPULATIONS:
l/
CITY USE ONLY
Fee Schedule on Reverse Side
.001 of Permit Valuation (1/10th%)
$.50/$1,000 Valuation
$1000 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 [ J
�k
8m16— 1 l
C41OIX V��D
WELL OR BORING LOCATION
MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring ,
WELL AND BORING SEALING RECORD sea"n"'L� Minn Na llrtique Well No:
Minnesota Statutes, Chapter 1031 or W -series No.
- Mw.Utm�xsnaa rmorm)
` 16 04 9�
H 3
County Name a
Toff"
Township No.
Range No.
Section No. Fraction (sm. -► fg.)
Date Sealed
Date Well or Boring Constructed
��tl66
30
23I
23 r r
a�ay 2000
AM !Py 2
g
Numerical Street Address or Fire Number and City of Well or Boring Location
5909 sw sinftT
Depth Before Sealing h.
Original Depth ft.
Show exact location of well or boring Sketch map of well or boring
in section grid with 'X'. I location, showing propertySingle
lines, roads, and buildings.
N
AOU1FER(S)
Aqurier ❑ Multiaquifer
STATIC WATER LEVEL
Measured ❑ Estimated
DAY ft. below ❑ above land surface
WELLIBORING
(WaterSupply Well ❑Monit.Well
❑ Env. Bore Hole ❑ Other
-T- -;-- --'�--li
VJ E
, TI
--L - ---- -i-- --i-- I
CASING TYPE(S)
Steel E] Plastic E] Tile ❑.Other
Acme ISI
-- - -i - -1-- --i
S .�11""
. r moo -
1
CASING(S)
Diameter Depth Set in oversize hole? Annular space Initially grouted?
' /�/
An. from 0 to I S ft. ❑ Yes ;°No ❑ Yes ❑ No ❑ Unknown
it
L
from to ft. C]Yes ❑ No C)Yes ❑ No ❑ Unknown
in. from to ft. ❑ Yes. ❑ No ❑ Yes ❑ No ❑ Unknown
PROPERTY OWNER'S NAMEn.
PLADIMM
Property owner's mailing address if different than wall location address indicated above.
,�.�
s qoq - STH ST` ' a ' 14, E
SCREENIOPEN HOLE
FRY T HN SS432
Screen from 15 to I'S ft. Open Hole from to ft.
OBSTRUCTIONS
❑ RodslDrop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill E(No Obstruction
Type of obstructions (Descnbe) —
WELL OWNER'S NAMESAM
Well owner's malling address if different than property owners address indicated above.
Obstructlons removed? ,.❑ Yes ❑ No . Describe ----
PUIMP
r
Type SHAMAN
Removed ❑ Not Present ❑ Other
X _
GEOLOGICAL -MATERIAL
COL
HARDNESS OF
FORMATION
FROM
TO
N not krawIt i dicate astiroet�A fi)Pndibn b9 tion Nearby welt or boring. • „. -.. _ '
METHOD USED, TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: r
No Annular Space Exists
1❑1
Annular space grouted with tremie pipe
CLAM
CRAY
2
❑ Casing Perforadon/Removai
In. from to ft ❑ Perforated ❑ Removed
31 -
KA=ISAIM
In. from to .' ft. ❑ Perforated ❑ Removed
of perforator
❑ Other
iType
GROUTING MATERIALS) (Once bag of cement = 04 tbs.. one bag of bernerilte = 80 ma.)
Grouting Material PcqrrLAM from is to 0 ft. yards � bags
from:=_ to ft. yards bags
from .a toft. ards bags
W
from to ft. yards bags
II
REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING
OTHER WELLS AND BORINGS
(;EX)14GY FR(W.- 7620 UNIVERSITY A
WATM LEVEL = A*0VE WML I
DATE WA L ELI! "�° : 06 /24/6
r uns well or boring an property? ❑ Yes ANo How many?
IMBEDCONTRACTOR CERTIFICATION
ia well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The Information contained In this report Is
'i`hhto the best of my knowledge.
MAP COIDE / E-11
S. E
SEA,D,
E. H. RENNER SMS: 71015
Contractor Name lloLicense orReglsfretlon No.
r
'"sl��ar� _ - '� �' '`
R rasa"
According to MN Sate Regulations
LOCAL COPY i1 169499
(Person Wap orBod