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PRE 2010 DOCS• City of Fridley, Mum. BUILDING PERMIT N° 3132 Date: .....<.. .....� j ...... Owner.. .. s. Builder ... ... ..... >I. ... ...... Address ..�� . - .✓r ........Address .....fJ..!.. ~ . ...... ... ... .. .. . e LOCATION OF BUILDING No. ®f�.. Street .q ......................... Part of Lot ........ Lot .... �7...... Block .... ....... Addition or Sub -Division ....... .... ..w . . Corner Lot ............ Inside Lot ............ Setback ... �.. Sideyard ..°�. .. �d�? . ./4 DESCRIPTION OF BUILDING To be Use as:, . .... .... Front .. Depth o� )e.. Height�q. Ft. .� V. ® Cu. Ft. ........ Fro ........ Depth Height ... Sq. Ft. ........ Ft. Type of Construction Est. . • • .. �aq.. To be Completed ...���. In consideration of the, issuance to me of a permit to construct the building desribed 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. v gle 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 with- in the city limits and this permit may be revoked at any time upon violation of any of the provisions of said ordinances. 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. October 5, 1970 Victor Zick 6021 - 5th Street N.E. Fridley, Minnesota I, Victor Zick, in conjunction with building a garage at my property at 6021 - 5th Street N.E. agree to install a hardsurfaced driveway from 5th Street to said garage by September 1, 1971. The reason for said request being that I shall be doing work on the garage myself; therefore, the season will be tgoadvanced to allow the pouring of a concrete driveway. c' 1 d VICTOR Z CK 0 Date: MW 27, X965 oma: Victor Zick City of Fridley, Minn.. BUILDING PERMIT N? '7594 Builder American Builders Inc. Address 6021 5th, St. N. E. Address 515 W. Broadvay LOCATION OF BUILDING No. 6021 Street 5th. St. N. E. Part of Lot Lot s_ _ 6 _ Block Addition or Sub -Division Bonn' Add. 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 94.72040 To be Completed Storm Damage Repair In consideration of the issuance to me of a permit to construct building descrIbed a e I agree to do the proposed work in accordance with the description above set fo anc� in p ce ail provisions of ordinaacxs of the city of Fridley. In consideration of the payment of a fee of $ 10-0(L Permit is hereby granted to 9merir•nv, Aldgtra Ina: 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 hid agents, employees anc3 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 gg location, conatructton, alteration, maintenance, repair and moving of buildings within the city limitsrtbia permit may be revoked at any time upon violation of any of the provisions of said ordinances. _ V 077 . NOTICES fhb permit don not cava the contraction, hm tallatton for vArk& phmbin& gn hes&& surer w water. Be sane to see the eatiding Deter for separate permits fa these Ban. f : A;PPLIlCATION, FOR BUILDING PERMIT • rl x••77 OF FRIDLE,Y� MrMSt OWNER'S'NAME BUILDER' tee...® ADDRESS_ -yk P ADDRESS LOCATION•OF'BUILDING No. (o 0 `a- l -) '-, ( Street Part of Lot___.____ LOT BLOCK ADDITION OR SUBDIVISION l 1C.0�e Corner Lot*_Inside L _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 Ta'be'used 'as: - Front Depth. Height $q. Ft. Cu. Ft. Front Depth Height' Sq. -Ft. Cu. Ft. Type. of Construction E,sticQated Costso.. A 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'L,� SIGNATUM (Schedule of Fee Costs can be found on the Reverse Side). �,d•.�i. °° " `�•�� ��i„N.a..., t,� .N•Q....Q„•�.�J � ��C�Ao,J,-'�l,R,,[� � �.®. 1 _ � Date: City of Fridley, Minn.. BUILDING PERMIT October 23, 1970 'NQ10 69) Owner. Victor Zich Builder Sussel Company Address 6021 -5th Street N.E. Adm 18510 Como Avenue St. Paul LOCATION OF BUILDING No. 6021 Street_ 5th Street N.E. — Partof Lot Lot — 6 --Block 2 Addition or Sub -Division _ Bonny Addition Corner Lot --- Inside Lot _. X.._..—_, Setback Sewer Elevation Sideyard Foundation Elevation DESCRIPTION OF BUILDING To be Used as: Garage int 22' Depth 22 Height 10Sq. Ft. 484' Cty Ft 4284 Front Depth __ _ Height Sq. Ft. Cu. Ft. Type of Construction Frame Est. Cost _ $1.,400.00 __ To be Completed 90 Days Hump in Drive to be cut when Driveway installed. Provide Hardsurfaced Driveway. 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. // „ A In consideration of the payment of a fee of $ 9.00 , permit is hereby granted to Sussel Company to construct the building or addition as described above. Thispermit 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 permit may be revoked at any time upon violation of any of the provisions of said ordinances. 6 NOTICE: rnb perk does not cover the construction, homffi tion for wiring, plumbing, gas boding, sorer or water. Bo am to as the Building hapeetar for separab permka for than hems. 40 • APLICATION FOR RESIDENTIAL, ALTERATION, OR ADDITION BUILDING PERMIT CITY OF FRIDLEY, MINNESOTA OWNER'S HAM: BUILDER: ADDRESS: �a / - �5�'-`'f`� f ��G . ADDRESS NO:. STREET: LOT: BLOCK: ADDITION: CORNER LOT: INSIDE LOT: SETBACK: SIDEYARD: 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: dg_c4e_J Q-a!:�o, Front: Depth: J)- Z Height: /o Square Feet: YY Cubic Feet: Front: Depth: Height: Square Feet; Cubic Feet: 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 sttict 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:'. 0 -;� - '/57%c, SIGNATURE: (See Reverse Side For Additional Information.) � i.�._ � � • ,� A b f' F F ". � Y�' `!� f'L✓` q � G� ® ,,��! :�'� �?! eF^ �it —' w Ilk B. H, BRADLEY CmLlo' domain AND SURVRYOR ff C��� -J!`, �Nt'^s.�►T, �� '�.. awes-zsxR AveNuesoufx Mme. Ua, 00 . E 1 .I CM y jl IA r f all �.. P.dJfett� c .., bU NO 1 i I f C r.,n - A-7 d_=% LOT N SIZE BLOCK # Z. ADDRESS oz '"" S VALUE t o ADD'N. AREA TYPE & m-) AC"N o %%j & ce ES H Ti4mPir 16 D,c O C6AJ0 >i r-/'.; of 11D` - I�oo ems. �l 0 2' A,a/zo�v I Bot -r5 Mb -cq ® 5�a Ue-,eE � 005c Sc) v — ie7 iZCMOU�D eb000 rr As ljcy"L= o 7 op ®ir SL-x�.e- -rz---, Be 4" %move a2hr.>E Pot1JT SHow$j 0 '7`2a�tlT SUBJECT PE City of Fridley 21432' 1432 AT THE TOP OF THE TWINS BUILDING PERMIT 71/ i � R O. �• COMMUNITY DEVELOPMENT DIV. J (� _ v PROTECTIVE INSPECTION SEC. r !tel iCITY HALL FRIDLEY 55432 NUMBER REV DATEPAGE OF APPROVED BY !"'"" �'' 612-571-3450 910-F15 7/6/92 JOB ADDRESS 6021 - 5th Street NE 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 6 2 Bonny Addition SHEET 2 PROPERTY OWNER MAILADDRESS ZIP PHONE Victor/Alice Zick 6021 - 5th Street NE 571-3745 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Same 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW �1 ADDITION ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct a 201 x 161 Deck and Add Glass Door 9 CHANGE OF USE FROM TO STIPULATIONS See notations on plan, 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 60 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 $2,457 $1.23 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 PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING CON- $54.00 Fire SC $2.46 SThUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTAL FEE $57.69 SIGNATU EOFC NTRACTOR OR AUTHORIZED AGENT IDATEIHE PROPER Y�V IDATED THIS IS YOUR PERMIT L LDG INSP DATE SIG A UREO OWNERI WNE UILDERI IDATEI NEW [ ] ADDN [ ] ALTER [ ] Construction Address: Legal Description: CITY OF FRIDLEY SINGLE FAMILY AND DUPLEXES R-1 AND R-2 Building Permit Application Owner Name & Address: Contractor: Address: Effective 3/1/92 Tel. # S7/- 3 `% 4�5 MN LICENSE # Tel. # 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. Ft. DECK AREA: Length A 0 � Width / eo � Hgt/Ground Sq. Ft. OTHER: �a/A 4 loo 2 Comer Lot [ ] Inside Lot [ Ft. Yd Setback _ Type of Construction: T a?�Vo Approx. Completion Date: Driveway Curb Cut Width Needed: Ft. + 6 Ft = Side Yard Setbacks Estimated Cost: $ aYS 7 (Cost on Back) Ft x $ = $ DATE: APPLICANT: CITY USE ONLY Permit Fee $ 'r"4, ®® Fire Surcharge $ 21 146 State Surcharge $ / 2 SAC Charge $ License Surcharge $ --- Driveway Escrow $ Park Fee $ Sewer Main Charge $ TOTAL $ 7.65 STIPULATIONS: Gt)"-7f a - Tel. # /a o 6 - 7i 3 715 Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $700 per SAC Unit $5.00 (State Licensed Residential Contractors) Alt. "A" or Alt. "B" Above Fee Determined by Engineering Agreement Necessary [ ] Not Necessary [ ] r B. .",,BRADLEY CIVIL ENGINEER AND SURVEYOR 88a9.zarN AVENUE SOUTH MINMiPO&M. MOU"MrA SM 724-2169 sifrvq 4ml I Y L ff AV l6f ki Pf 76'• WI 3* -%,r T- - -- — • ani I s PICK�•lfp CONST t+ASSES 6eLY t 'STORE AI?pF20V MRN - i F DEVICE USED ON: TITLE • _ E D NEXT ASSY. NO - C DRWO. NO. v B maaaon&psCwm DR.i CH. SCALE A ... aPLOM PLDEC. * DATE SH! OF _ ' REV REVISION DESCRIPTION _ 1110 Podi..'t,�n S..vUu I mwa�ff I (3 3 17 Y16 SUBJECT PE City of Fridley 2948 AT THE TOP OF THE TWINS BUILDING PERMIT r COMMUNITY DEVELOPMENT DIV. r v PROTECTIVE INSPECTION SEC _IK NUMBER REV DATEP AGE OF APPROVED By CITY HALL FRIDLEY 55432 612-571-3450 910-F15 9/26/94 JOB ADDRESS 6021 5 Street NE I LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 6 2 Bonny Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Alice Zick 6021 5 Street NE 571-3745 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO Ovall Roofing & Const. 6730 213 Ave NW, Elk River MN 55330 753-2959 360 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 x ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Aluminum soffit & fascia; reside garage; garage service door, 2 prime doors & storms; reinsu ate attic vent; weatherstrip windows 9 CHANGE OF USE FROM TO STIPULATIONS Provide smoke detectors adjacent to all sleeping areas. Ventilation to be in compliance 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 I HAVE READ AND EXAMINED THIS APPLICATION 1 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 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $7,000 $3.50 PERMIT FEE SAC CHARGE DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER TAT OR-LOCAL LAW REGULATING CON- SC $7.00 STRUCTION PERFOR E O C NS U ON $90.00 Fire PLAN CHECK FEE TOTAL FEE License SC $5.00 $105.50 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DATE' WHEN VALIDATED THIS IS YOUR �PROPERLY ,,,BLD 'NSP �PERMIT DATE SIGNATURE OF OWNERIIF OWNER BUILDERI (DATE) 1 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R -Z Building Permit Application Construction Address:�p !�/ J* Effective 1/1/94 Legal Description: (� Owner Name & Address: 7 "c a i c'n/i Tel. # Contractor: �/ // /�00 MN LICENSE # Address: /�� �,3 ✓� ,� Ll -- S Tel. # 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. Ft. DECK AREA: Length Width Hgt/Ground Sq. Ft. OTHER: o �5 Soar, F/'1As, 4, 2eSi � c ±,� Corner Lot [ ] Inside Lot [ ] Ft. Yd Setback Side Yard Setbacks Type of Construction: Approx. Completion Date: _ Estimated Cost: $ `,2aeC© _ (Cost on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ — $ DATE: APPLICANT: ���� Tel. # , .�7�% �7 z .� 3 Permit Fee Fire Surcharge State Surcharge SAC Charge License Surcharge Driveway Escrow Erosion Control Park Fee Sewer Main Charge TOTAL STIPULATIONS: $ 10SS,s_D CITY USE ONLY Fee Schedule on Reverse Side .001 of Permit Valuation (1/10th%) $.50/$1,000 Valuation $$00 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 [ ] a SUBJECT P City of Fridley 2 715 2 AT THE TOP OF THE TWINS BUILDING PERMIT r 1 , )MCIEPT NO. COMMUNITY DEVELOPMENT DIV. PROTECTIVE INSPECTION SEC. r I 1 � —613 NUMBER REV DATE PAGE OF APPROVED BY = CITY HALL FRIDLEY 55432 612-571-3450 910-F15 8/12/98 JOB ADDRESS 6021 5 St 1 LEGAL LOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 6 2 Bonney Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Alice Zick 571-3745 3 CONTRACTOR MAIL ADDRESS ZIP PHONE LICENSE NO. Hardies Home Alterations & Repair 290 Cherry Hill Trail,Medina 478-3123 4 ARCHITECT OR DESIGNER MAIL ADDRESS ZIP PHONE LICENSE NO. 20074367 5 ENGINEER MAIL ADDRESS ZIP PHONE LICENSE NO. 8 USE OF BUILDING Residential 7 CLASS OF WORK ❑ NEW ❑ ADDITION ❑ ALTERATION XX REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Reroof house and garage 23 S Tear-off 9 CHANGE OF USE FROM TO STIPULATIONS Underlayment must comply with 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 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 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 1918 $.96 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 R T PER ORMA OF CONSTRUCTION. $62.25 Five SC $1.92 e PLAN CHECK FEE TOT L FEE Licen S 5 0 0.13 GNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DA T I EN R LID D THIS IS ffPIT SIGNATURE OF OWNEROF OWNER SUILDERI IDATEI L -NSP a NEW [ ] Effective 1/1/98 ADDN [ J CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R-1 AND R-2 BUILDING PERMIT APPLICATION ConstructionAddress: ( — . NE Legal Description: Owner Name & Address: A c_ Tel. # S--7 " 3 -7 q S' Contractor: (rtRVtut1evt4 v MN LICENSE# 2 7 L(3(v-7 Address: D� 1�0 �i ear. r P< < I � k 'V� c(� �g Tel. # Attach to this application, a Certificate of Survey of the lot, with the proposed construction drawn on it to scale. DESCRIPTION OF EMPROVEMENT LIVING AREA: Length Width Height Sq. Ft. GARAGE AREA: Length Width Height Sq. Ft. DECK AREA: Length �J Width Hgt/Ground Sq. Ft. OTHER: Q a V. J c,-* rc-5 e_ '- - -7 91 _ -t-Mci Construction Type: Estimated Cost: (Fee Schedule on Back) Driveway Curb Cut Width Needed: Ft. + 6 Ft = Ft x $ _ $ DATE: _ (� �� APPLICANT: 4/n Tel. # CITY USE ONLY Permit Fee $ -2J—Fee Schedule on Reverse Side Fire Surcharge $ 9,� .001 of Permit Valuation (1/10th%) State Surcharge $ '96 $.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 $ ?o . 13 STIPULATIONS: li WELL OR BORING LOCATION „ MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 296752 WELL AND BORING SEALING RECORD Sealing County Name Minnesota Unique Well No. Minnesota Statutes, Chapter 1037 or W ser esbNo ANOKA Township Name Township No. Range No' Section No. Fraction (sm. —� Ig.) Date Sealed Date Well or Baring Constructed FRIDLEY 30 24 23 SE NL N*Friday, June 17, 2011 1958 iPS Latitude degre OCATION: Longitude_ degree lumerical Street Address or Fire Number and 6021 - 5TH STREET NE, FRID how exact location of well or boring i section grid with "X." , u EVER Nunn'I Annular space Initially grouted? ❑ Yes EXNo 0 RENEII ❑ Yes ❑ No ❑ Unknown t WELLHEAD COMPLETION Outside: ❑ Well House ❑ At Grade RENS' To, Prior Removed Shallow Well Jet Pump... ❑ Removed [XNot Present ❑ Other If not known, indicate estimated formation log from nearby well or boring. If GEOLOGY FROM:60 b I Mile PROPERTY OWNER'S NAME/COMPANY N THEISEN. EUGENE & KAREP Property owner's mailing address if different than 6021 - 5TH STREET NE FRIDLEY, MN 55432 es - minutes_ seconds Depth Before Sealing 25 ft. Original Depth CWI no record ft SI minutes_ seconds AQUIFER(S) STATIC WATER LEVEL Ci(Y of Well or Boring Location [(Single Aquifer ElMultlaquffer LE f, 55432 WELLMORING EXMeasured ❑ Estimated Date Measured 0 [(Water -Supply Well ❑ Montt. Well f Sketch map of well or boring 15 location, showing property El Env. Bore Hole ElOther ft. [below ❑ above land surface lines, roads, and buildin . CASING TYPE(S) A g�8e (ysteel ❑ Plastic ❑ Tile ❑ Other Galvanized T&C cjl Annular space Initially grouted? ❑ Yes EXNo 0 ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown t WELLHEAD COMPLETION Outside: ❑ Well House ❑ At Grade '�jj To, Prior Removed Shallow Well Jet Pump... ❑ Removed [XNot Present ❑ Other If not known, indicate estimated formation log from nearby well or boring. If GEOLOGY FROM:60 ❑ Pitless Adapter/Unit Buried house r=M0 ❑ Well Pit 28 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: [}Qlo Annular Space Exists E] Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal In. from to ft. ❑ Perforated ❑ Removed In. from to ft. ❑ Perforated ❑ Removed Type of Perforator ❑ Other ►MR CASING(S) Diameter Depth well location address Indicated above 1.25 in. from 1 to 22 ft. II in. from to ft. In. from to ft. Inside: ❑ Basement Offset ❑ Well Pit ❑ Buried ❑ Other Set In oversize hole? Annular space Initially grouted? ❑ Yes EXNo ❑ Yes ❑ No ❑ Unknown ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown ❑ Yes ❑ No [I Yes ❑ No ❑ Unknown YELL OWNER'S NAMEICOMPANY NAME SCREEWOPEN HOLE Screen from 22 t0 25 ft. Open Hole from to ft. Vol] owner's mailing address Ifdifferent than property owner's address Indicated above i SAME OBSTRUCTIONS ❑ Rods/Drop Pipe ❑ Check Valves) ❑ Debris ❑ FlII [No Obstruction Type of Obstructions (Describe) NO Obstructions Obstructions removed? ❑Yes ❑ No Describe GEOLOGICAL MATERIAL COLOR I HFORMA ONR FROM TO To, Prior Removed Shallow Well Jet Pump... ❑ Removed [XNot Present ❑ Other If not known, indicate estimated formation log from nearby well or boring. If GEOLOGY FROM:60 5 - 7TH $TF EET NE Sand j r=M0 28 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: [}Qlo Annular Space Exists E] Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal In. from to ft. ❑ Perforated ❑ Removed In. from to ft. ❑ Perforated ❑ Removed Type of Perforator Cla 28 No Record iI 38 40 Static Water - 30' - IIIii Monitor Well 2"X40' ii ❑ Other GROUTING MATERIAL(S) (One bag of cement = 94 Ibs., one bag of bentonite = 50 Ibs.) Grouting Material Neat Cement from 1 to 1 5 ft. 0-046 bags Enviroplug from 1.5 tc 25 ft 2.162 APlbns bags fromto ft. 0 yQdD_RS bags OTHER WELLS AND BORINGS REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes ()No How many? Well Buried 6' East Side Of House LICENSED OR REGISTERED CONTRACTOR CERTIFICATION I This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The Information contained in this report Well Depth Measured From Grade Level is true to the best of my knowledge. M.D.H. Inspector Was Not On Site During Well Sealing Myron L. Malenke / Malenke Water (763) 493.3650 1426: A j; Llcense slness Nam9. / License or Registration No. Received Well Sealing Not Cap From M.D.H ,y it ' M. L. Malenke - 347: A June 17, 2011 p}p 23 30 24 21 0636 Certified Representative Signature Ceffled Rep. No. Date LOCAL COPY �'H 296752 Name of Person Sealing Well or Boring HE -01434-12 IG# 140-0423 siosa