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PRE 2010 DOCSMEW OCT 13196 U Application for Power Plants and Floating, Cooling, Ventilation, Refrigeration and / Air Conditioning Systems and Devices ��?ARTIAL RATE SCHEDULE CiRi_TY R: RATE TOTAL e11 & Duct Work ........................... 8.00 $ Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 .................. 5.00 $ Repairs & Alterations each add. $500.00 ............... 2.50 $ MECH. WARM AIR Furnace Shell & Duct Work to 120,000 BTU ............ 8.00 $ each add. 60,000 BTU ....................... 2.00 $ Replacement of Furnace ............................. 5.00 $ Repairs & Alterations—up to $500.00 ................. 5.00 $ Repairs & Alterations each add. $500.00 .............. 2.50 $ STEAM or HOT WATER SYSTEM Furnace Shell & Lines—to 400 sq. ft. EDR Steam ..... 8.00 $ Furnace Shell & Line—to 640 sq. ft. EDR Hot Water ... 8.00 $ Each add. 200 sq. ft. EDR Steam ...................... 2.50 $ Each add. 320 sq. ft. EDR Hot Water ................. 2.50 $ OIL BURNER—to 3 gal. per hour ........................ 5.00 $ over 3 gal. per hour—See Fee Schedule GAS BURNER (up to 400,000 BTU) ....................... 5.00 $—A�6 GAS FITTING FEES: NO RATE `O AL 1st 3 Fixtures ...................... x $1.50 $ / (J Additional Fixtures ............... x .50 $ Gas Range to 200,000 BTU ........... x 2.00 $ AIR CONDITIONING FAN HEATING SYSTEM VENTILATING SYSTEM ALTERATIONS & REPAIRS ROUGH FINAL See Fee Schedule TOTAL FEE Dept. of Bldgs. Phone 560-3450 Location Z3 4.13 6 (-/, a--,� ' h,6 City of Fridley: 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 representations stated in this application are true and correct. Fridley, M/inn_ �CJ�/ �O. 18 Owner Kind of Building Used as - ai To be completed about Estimated Cost, $� O Old New. Building Permit No. Permit DESCRIPTION OF WORK HEATING or POWER PLANTS -Steam, Hot Water, Warm Air—No Trade Name Size No Capacity Sq. Ft. E.D_R- BTU ,Q H.P. Total Connected Loa Kind of Fuel BURNER — Trade Nam Size NolC� Capacity Sq. Ft. E.D.R BTU H.P. (REMARKS -OVER) 7Byjj- 42 Business �II�EGo 53-84-s-915.51 Cir j of Fridley Appliceicn for Plumbing end Gas r.1 n.0 POTM.;t - Dept. of Bldgs. Phone SM -34W DESCRIPTION OF tIOR: 1387 N. E. -66th. Ave. Numbar, Kind a.nd Looe -Ken of Fixtures - i •; � 7 S r • N �; .• Future Fixture Opening ............ x $1.50 S -. New Fixture Old Opening.......... x $1.50 N i Catch Basin .................... x $3.25 WATER NTN. e x $3.00 S New Ground Run Old Bldg.......:. x 53 "5 $ Electric r H.aton...... • •o Ins ail LS FITTING FEES rA Ist 3 Fixtures ............ • • • • • • x $2.00 Additional Fixtures .............. x $ .75 S Gas Range to 199.000 BTU ........... x $5.00 4 Futuro Conacctiaa Oponings sever 0 Now Fixture. Old Oponings - Ccwpool C] PARTIAL RATE SCHEDULE MMMBING FIXTURE RATES: NO. RATE TOTAL Number Fixtures ................ x $2.00 $ Future Fixture Opening ............ x $1.50 S -. New Fixture Old Opening.......... x $1.50 Catch Basin .................... x $3.25 $ Water Beater !L'p to 99.000 BTU) • • • • x $3.00 S New Ground Run Old Bldg.......:. x 53 "5 $ Electric r H.aton...... • •o a G LS FITTING FEES NO RATE TOTAL Ist 3 Fixtures ............ • • • • • • x $2.00 Additional Fixtures .............. x $ .75 S Gas Range to 199.000 BTU ........... x $5.00 4 City of Fridley: The undersigned hereby makes application for a permit for the work her ei specified, a;reeing to do all work in strict accordance with the Citi Ordirunce and ruling of the Department of Buildings, and hereby declares that all the fact and representations stated in this application are true and correct" Fridley, Mian 4-25-75 19. Owner Roland Zacharies Kind of Building Frame Used as Res. To be completed about 5-2-75 -- Estimated Cost, $ 10.00 Old 34A63iiKBuilding Permit No. •' IO Signed MINNE&M• ROUGH nNAL �i -'q q-76 CPAIRS a ALTERATIONS—Refer to Code .50 State Surcharge 11���( Tnstall Dryer � 5.00 • Description ..................... .. .. A ............. , `:. , . • ♦V+ALrZE = 5.50 - Ows ffAff-T Surcharge, .500 - By -- Business Phone No C City of Fridley SUBJECT P 1 14022 AT THE TOP OF THE TWINS PERMIT' i BUILDING - RE PT NO. I COMMUNITY DEVELOPMENT DIV. r I � PROTECTIVE INSPECTION SEC. F610 I; � CITY HALL FRIDLEY 55432 G J� NUMBER REV. 1 DATE 1 PAGE OF APPROVED BY 612-560-3450910-F15 1 14/22/77 JOB DRESS 1363 - 66th Avenue N.E. I NO. BLOCK TRACT OR ADDITION SEE ATTACHED 4 Dennis Addition SHEET jLOT YOWNER MAILADDRESS ZIP PHONE C. Leonhardt 1363 - 66th Avenue N.E. CTOR MAILADDRESS ZIP PHONE LICENSE NO. Same `. 4 ARCHI CT OR DESIGNER MAILADDRESS ZIP PHONE LICENSE NO. 5 ENGINEE , MAILADDRESS ZIP PHONE LICENSE NO. 6 USE OF BUI 1NG Residentiik 7 CLASS OF WO ❑ NEW ❑ ADDITION ❑ ALTERATION l REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WOR Reroof Telling 9 CHANGE OF USE FR TO STIPULATIONS / 1. SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOADAS VENTILATING OR AIR CONDITIONING. P halt 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 $ 50 WITH WHETHER SPECIFIED HEREIN OR NOT. THE GRANTING OF A PERMIT $790.00 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 PERFOR CE OF gONSTRUCTION. $7.50 PLAN CHECK FEE TOTAL FEE 0 2� $8.00 SIGNATUREOFCON A ORORAUTHORIZEDAGENT IDATEI WHEN PR PERLY VALIDATED THIS IS YOUR �PERMIT y -�?C SLOG INSP ( OATE SIGNATURE OF OWNER IIF OWNER BUILDERI IDATEI 01 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 QESIDEhTIAL RATE TOTAL Job Address Furnace Shell and Duct Work, Burner (Also replacement furnace) $ 20.00 $ Department of Buildings, 6431 University Ave. N.E., Fridley, MN 55432 6 City of Fridley Gas Piping $ 10.00 $' . Tel. #571-3450 (piping needed with new furnace) Gas Range $ 10.00 $�_� 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 Gas Dryer $ to. 0i $ and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. • Air Conditioning (all sizes) $ 10.00 S Fridley, Minn. All Others/Repairs and Alterations It of Value of Appliance or Work $ COMMERCIAL/INDUSTRIAL It of Value of Appliance or Work OWNER KIND OF BUILDING USED AS $ TO BE COMPLETED ABOUT ESTIMATED COST State Surcharge $ .50 TOTAL FEE $ Reinspection Fee ($15.00) S Rough Insp. Date Final Insp. Date Approval for Permit MINIMUM PEE 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. OLD - NEW BUILDING PERMIT NO. PERMIT NO. DESCRIPTION OF FURNACE/BURNER HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. Trade Name Size No. Capacity Total Connected Load BURNER - Trade Name Capacity Sq. Ft. EDR BTU Kind of Fuel Size No. HP Sq. Ft. EDR BTU HP Company - Signed By Tel. No. Fill out back side for stack verification on replacement furnaces 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 ( ) 4. Is securely supported Yes ( ) No ( ) 5. 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 Rema rk s Company _ Signed By Da to Effective May 1, 1990 CITY OF FRIDLEY APPLICATION FOR PLUMBING AND GAS FITTING PERMIT tn uJ u a a S 5.00 in W k 1. li to c a o re a y . q w u o� Ux u 4 z p, 3 .• w e a t1i o Water Heater 'as 'lec $ $ 5.00 $ $ 5.00 $ $ 5.00 $ $ 5.00 $ $ 7.00 $ 7,v0 $ 5.00 lot $ 10.00 $ E� $ 10.00 $ 2nd ]rd 4th (R) - Future Connection Opening Connected with Sewer (') a Now Fixture, Old Opening Water RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL AW Fixtures OPRAJW. .' %60 Exap— chd opening, now Fixture Beet Dispenser Blow off Basin Catch Basin Rain Water Leader Hydraulic valve Sump or Receiving Tank Water Treating Appliance Amm water Heater Gis Rafige Gas Dryer Back Flow Preventer Required. . . Yes ( ) No ( ) Type $ s Yo, ba ALL OTHERS AND/OR REPAIRS AND ALTERATIONS It of Value of Fixture or Appliance S Reinspection Fee S State Surcharge S .50 ��� TOTAL FEE $ Job Address Department of Buildings City of Fridley Tel. 1571-3450 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 declare& that all the facts and representations stated in this application are true and correct Fridley, Mn. . 19 OWNER KIND OF BUILDING USED AS TO BE COMPLETED ABOUT ESTIMATED COST OLD - NEW BUILDING PERMIT NO. G. -t company - Signed By Tel. No. ROUGH INSP. Date FINAL INSP. Date APPROVAL FOR PERMIT PERMIT NO. !11NIf11J4 FLE FOR ANY PLUMBING PERMIT I :15.00 PLUS THE $.50 STATE SURCHARGE :_ _. S 5.00 $ 1.50 $ 7,00 $ 4.00 S '7�a $ 5.00 $ $ 5.00 $ $ 5.00 $ $ 5.00 $ $ 5.00 $ $ 7.00 $ 7,v0 $ 5.00 $ $ 10.00 $ E� $ 10.00 $ Back Flow Preventer Required. . . Yes ( ) No ( ) Type $ s Yo, ba ALL OTHERS AND/OR REPAIRS AND ALTERATIONS It of Value of Fixture or Appliance S Reinspection Fee S State Surcharge S .50 ��� TOTAL FEE $ Job Address Department of Buildings City of Fridley Tel. 1571-3450 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 declare& that all the facts and representations stated in this application are true and correct Fridley, Mn. . 19 OWNER KIND OF BUILDING USED AS TO BE COMPLETED ABOUT ESTIMATED COST OLD - NEW BUILDING PERMIT NO. G. -t company - Signed By Tel. No. ROUGH INSP. Date FINAL INSP. Date APPROVAL FOR PERMIT PERMIT NO. !11NIf11J4 FLE FOR ANY PLUMBING PERMIT I :15.00 PLUS THE $.50 STATE SURCHARGE :_ _. 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 RESIDEI�TL#L RATE TOTAL Job Address Furnace Shell and Duct Work, Burner (Also replacement furnace) $ 20.00 $ Department of Buildings, 6431 University Ave. N.E., Fridley, MN 55432 City of Fridley Gas Piping $ 10.00 $ Tel. #571-3450 (piping needed with now furnace) Gas Range $ 10.00 $ The undersigned hereby makes application for a permit for the work herein specified agreeing to do all work in strict accordance with the City Cedes Gas Dryer $ 10.00 $ and rulings of the Department of Buildings, and hereby declares that all the facts and representations stated in this application are true and correct. • Air Conditioning (all sizes) $ 10.00 S Fridley, Minn. All Others/Repairs and Alterations OWNER It of Value of Appliance or Work S KIND OF BUILDING COMMERCIAL/INDUSTRIAL USED AS It of Value of Appliance or Work S TO BE COMPLETED ABOUT ESTIMATED COST State Surcharge $ .50 OLD - NEW BUILDING PERMIT NO. PERMIT NO. TOTAL FEE $ Reinspection Fee ($15.00) S DESCRIPTION OF FURNACE/BURNER Rough Insp. HEATING or POWER PLANTS, Steam, Hot Water, Warm Air- No. Date Final Insp. Trade Name size No. Date Capacity Sq. Ft. EDR BTU HP Approval for Permit Total Connected Load Kind of Fuel BURNER - Trade Name Size No. Capacity Sq. Ft. EDR BTU HP MINIMUM FEE FOR ANY HEATING PERMIT IS $15.00- Company PLUS $.50 STATE SURCHARGE Signed By Tel. No. *Air Conditioners can not be placed in side yard without written permission from adjoining neighbor. Fill out back side for stack verification on replacement furnaces CHIMNEY AND STACK VERIFICATION The undersigned hereby verifies that the existing chimney or stack; 1. Has been carefully examined Yes ( ) 2. Is free from rust or deterioration Yes ( ) 3. Has no foreign objects lodged within Yes ( ) 4. Is securely supported 5. Meets all current Code requirements for size and total BTU connected 6. Has Total heating BTU's of All other BTU's TOTAL Rema rk s Company Signed By Da to Yes ( ) No ( ) No No ( ) No ( ) Yes ( ) No ( ) Effective May 1, 1990 CITY OF FRIDLEY APPLICATION FOR PLUMBING AND GAS FITTING PERMIT RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE H New Fixtures e $ 5.00 U Future Fixtures x w $ Mater A 2 .- � $ 4.00 k c a �� $ 5.00 e� w w w 5 Rain Nater Leader Heater $ 5.00 $ Hydraulic Valve � $ Sump or Receiving Tank ,,� $ 5.00 $ Nater Treating Appliance $ 7.00 $ a� $ 5.00 5 Gas Range w O S Gas Dryer e $ 10.00 a G •moi y O O N W u m N h C ALTERATIONS u a It of Value of Fixture or Appliance H S n w h w S .SO z o 'as 'lec U, U6 is let 2nd 3rd 4th (R) - Future Connection Opening Connected with Sewer (�) - New Fixture. Old Opening Water RATE SCHEDULE PLUMBING FIXTURE RATES: NO. RATE TOTAL New Fixtures $ 5.00 S Future Fixtures S 3.50 $ Old Opening, New Fixture $ 1.50 $ Beer Dispenser $ 4.00 $ Blow Off Basin $ 5.00 $ Catch Basin $ 5.00 $ Rain Nater Leader $ 5.00 $ Hydraulic Valve S 5.00 $ Sump or Receiving Tank $ 5.00 $ Nater Treating Appliance $ 7.00 $ Mot Nater Heater $ 5.00 5 Gas Range $ 10.00 S Gas Dryer $ 10.00 $ Back Flow Preventer Required. . . Yes ( ) No ( ) Type 5 S. u0 5 ALL OTHERS AND/OR REPAIRS AND ALTERATIONS It of Value of Fixture or Appliance S State Surcharge S .SO Murinspsction Fee S ($15.00) TOTAL FEE $ Job Address Department of Buildings City of Fridley Tel. 1571-3450 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 oorrect Fridley. Mn. . 19 OWNER KIND OF BUILDING USED AS TO BE COMPLETED ABOUT ESTIMATED COST OLD - NEW BUILDING PERMIT NO. Compfiny - Signed By Tel. No. ROUGH INSP. Date FINAL INSP. Date APPROVAL FOR PERMIT PERMIT NO. 111NIH04 FEE FOR ANY PLUMBING PERMIT IS $15.00 PLUS THE S.50 STATE SURCHARGE SUBJECT P City of Fridley 2 O ��� AT THE TOP OF THE TWINS BUILDING PERMIT If? RECEIPT NO. COMMUNITY DEVELOPMENT DIV. ______ r I L -- PROTECTIVE INSPECTION SEC. l 3's �+ NUMBER REV DATE PAGE OF APPROVED BY CITY HALL FRIDLEY 55432 "'j 612-571-3450 910415 10/18/90 JOB ADDRESS 1363 - 66th. Avenue N.E. 1 LEGALLOT NO. BLOCK TRACT OR ADDITION SEE ATTACHED DESCR. 4 Dennis Addition SHEET 2 PROPERTY OWNER MAIL ADDRESS ZIP PHONE Kenneth/Judy Bigelow 1363 - 66th Avenue N.E. 574-1225 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 � ADDITION ❑ ALTERATION ❑ REPAIR ❑ MOVE ❑ REMOVE 8 DESCRIBE WORK Construct a 8'6" x 30.' Garage Addition 9 CHANGE OF USE FROM TO STIPULATIONS Provide a hard surface driveway, See notations on plan. Use 2x6 rafters or 401b Manufactured trusses on roof. TYPE OF CONST. OCCUPANCY GROUP OCCUPANCY LOAD SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL, PLUMBING, HEATING, VENTILATING OR AIR CONDITIONING. ZONING SO. FT. CU. FT. THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN BO DAYS, OR IF CONSTRUCTION R-1 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 $3,839- $1,92 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- STRUCTION OR THE PERFORMANCE OF CONSTRUCTION. PLAN CHECK FEE TOTALFEE Fire SC $3 84 8.76 SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT (DAT WHEN PRDP A D r IS OUR PERMIT J% P DATE SIGNATURE OF OWNER )IF OWNER BUILDER) (DATE) NEW [I Effective 3/1/92 ADDN [ ] CITY OF FRIDLEY ALTER [ ] SINGLE FAMILY AND DUPLEXES R -I AND R-2 Building Permit Application F�- Construction Address: 13 Co 3 Legal Description: D Owner Name & Address: ��� % QX�p-t. � Tel. #=�C-j Y--L:zD Contractor: Address: 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 Width Hgt/Ground Sq. Ft. OTHER: Corner Lot [ ] Inside Lot [ ] Type of Construction: Approx. Completion Date: Ft. Yd Setback Side Yard Setbacks Estimated Cost: $ 13, bp(Cost on Back) Driveway Curb Cut Width Needed:_�oFt. + )VFt = Ft x $ i. Ste_ _ $ DATE: O/— APPLICANT: 6I Tel. L Permit Fee $ Fire Surcharge $ State Surcharge $ SAC Charge $ License Surcharge $ Driveway Escrow $ Park Fee $ Sewer Main Charge $ TOTAL STIPULATIONS: CITY USE ONLY Fee Schedule on Reverse Side' 3 .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 [ ] C. (a . . Minnesota Well and Boring WELL OR BORING LOCA DN Dn. MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 55411 County Name ELL AND BORING SEALING RECORD Minnesota Unique No. .�4� Minnesota Statutes, Chapter 1031 or W -series No. E *!j ,+ W mile i+oka -r 1 (Leave blank J not known) I -r- I Township Name rid e„ Fridley' Township No. Range No. I Section No. I Fraction (sm. . Ig.) 114 lla fra Date Sealed / 9( 5/94 `b° Approximate Date Well or Boring Constructed 1956 i I 1 l - Numeericall Street Address or Fire Number and City of Well or Boring Location � �� 4 � � { 1363 66th Avenue N.L. Depth Before Sealing ft. Original Depth ft. Show exact location of well or boring Sketch map of well or boringStatic Water Level Accurate in section grid with'X'. location, showing property lines, ❑ Approximate N It roads, and buildings. S Screen from — to ft. Open Hole from to ft. —smile --10 66 OBSTRUCTIONMEBRISIFILL Obstruction ❑ Debris ❑ Fill PROPERTY OWNER'S NAME' Xenneth & Judy Jigglotr Drop 3 o d Jet Type of debrislobstruction Mailing Address if different than property address indicated above. Obstruction/Debris/Fill removed? XYes ❑ No Jame PUMP L7 Removed ❑ Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? If not known, indicate estimated formation log from nearby well or boring. ,271� Drift 0 04 in. from 05 to 104ft. ❑Yes FNo ❑Yes CI No ❑Unknown +6� 5� in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown In. from to ft. ❑ Yes 0 No ❑ Yes ❑ No ❑ Unknown 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 PerforatiorJRemoval in. from to ft. ❑ Perforated ❑ Removed In. from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL q Grouting materia 0r",� 1 ?,n from 104 to ft. yards bags from to ft. yards bags REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING Sin. well located basement from to ft. yards bags of faet South side of hoase s from to ft. yards bags Removed puap t Removed from UNSEALED ! , UNSEALED WELLS AND BORINGS well 54f t a 11' 4' a . drop'; i pipe Other unsealed well or boring on property? ❑ Yes X No and jet. Total depth 104ft, 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 best of my knowledge. 011 Johns &- 43ons Drilling° 275-0 Contractor Busi ss ame License or Registration No. e Authorize Representative Signature Date LOCAL COPY H W C� Donn Johnson 9/ 5/94 Name of Person Sealing Well or Boring HE -01434-01 1 iv 96 er ❑ Multia Single Aquifer uifer below above land surface CASING TYPE W E *!j ,+ W mile 27steel [IPlastic ❑Tile ElOther -r 1 --I- I -r- I 1 -r 1 I I I I 1 l - S Screen from — to ft. Open Hole from to ft. —smile --10 66 OBSTRUCTIONMEBRISIFILL Obstruction ❑ Debris ❑ Fill PROPERTY OWNER'S NAME' Xenneth & Judy Jigglotr Drop 3 o d Jet Type of debrislobstruction Mailing Address if different than property address indicated above. Obstruction/Debris/Fill removed? XYes ❑ No Jame PUMP L7 Removed ❑ Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? If not known, indicate estimated formation log from nearby well or boring. ,271� Drift 0 04 in. from 05 to 104ft. ❑Yes FNo ❑Yes CI No ❑Unknown +6� 5� in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown In. from to ft. ❑ Yes 0 No ❑ Yes ❑ No ❑ Unknown 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 PerforatiorJRemoval in. from to ft. ❑ Perforated ❑ Removed In. from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL q Grouting materia 0r",� 1 ?,n from 104 to ft. yards bags from to ft. yards bags REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING Sin. well located basement from to ft. yards bags of faet South side of hoase s from to ft. yards bags Removed puap t Removed from UNSEALED ! , UNSEALED WELLS AND BORINGS well 54f t a 11' 4' a . drop'; i pipe Other unsealed well or boring on property? ❑ Yes X No and jet. Total depth 104ft, 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 best of my knowledge. 011 Johns &- 43ons Drilling° 275-0 Contractor Busi ss ame License or Registration No. e Authorize Representative Signature Date LOCAL COPY H W C� Donn Johnson 9/ 5/94 Name of Person Sealing Well or Boring HE -01434-01