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HomeMy WebLinkAboutDemolition Permit 07-0232 /0~IPR~JO<1' I~',/ / \~ >-1 / ~ U \{- ?iJ \ 1.:,~ O~~ '" , 'v IV E S "'- CITY OF l'RIOR LAKE DEMOLITION PERIVJT F,D. BUJeAJ Date Rec'd 2./4. D7 I PERMIT NO. G>1-232 (Please type or print and sign at bottom) ADDRESS !tp+77 HOWAJeO .v1J:::b ;etJ;Jt:}.f) ZONING (office use) LEGAL DESCRIPTION (offiCe use only) L rr BLOCK ADDITION PIDZ5: 901-. 008.() ~~\;~I~~R /VOJQ1lI'lOO.D6 I1EADOWS / P apAl~ I - ~(^,Jdress) CfJoS (,31t,O /Iv,;C..',t I'1ffP16 ~;e/)t/6_ ~ 4- fe/Cl1 ' CUNTRACTOR I -- (CompanyName)~/7V OF /? t. AIlE Ot:;P/ (Contact Name) i.J~tJ(j H/J/CTI'1,1/J! , (Address) S~vb'Mrt/Vld. ~ (PI, 'ne) b/7-- ---z.'fO-'~-<;7o HN 653"9 . (Phone) (Phone) 16Z. Z/6. ,9dS/ Use of Building: INTERNATIONAL BUILl 1lNG CODE Type of Construction: I:r HI IV V Occupancy Group: A B E F HIM Division: I 2 3 4 ~CA NOTIFICATION OF INTENT TO PERFORM A DEMOLITION A B R S U 5 I hereby certif I am the 0 and will I her at I have furnished information on this application which is to the best of my kno,vledge true and correct. I also certify that or auth ized gent for the above-mentioned property and that all construction will 'onforlll to all existing state and local laws ord ce wi SU.bmitted plans. I am aware that the building offtcial can revo:;e this !~ermit r r jus.t cause. Furthermore, me' or a designee may enter upon the property to perform needed insilecti~n's/ I; ~ 7 ____ y-// '/ t (- Signatu~ . (Date ~ =~ .~,. This Application 'Becomes Your Demolition e 'Whe~prove~ 4" 8 01 (Da ' Lf-/&,,- C?7 '/''/ Date Special Conditions, if any 24 hour notire for nil inspections (952) 447-9850, fax (952) 447-42.1:; 16200 Eagle Creek Avenue, Prior Lake, Minnesota 55372 Property Search Results Page 1 of3 Scott County Property Information Search Results General Property Information Property ID: Roll Type: Payable Year: Owner Name: Property Address: City/State/Zip: Taxpayer Name: Taxpayer Mailing Address: House Address: City/State/Zip: 25-904008-0 Rea I Estate 2008 NORTHWOODS MEADOWS LLC 16477 HOWARD LAKE RD NW SHAKOPEE MN 55379 NORTHWOODS MEADOWS LLC 9705 63 AVE N MAPLE GROVE MN 55369 Legal Description Information Lot/Block/Plat# : Section/Township/Range: Deeded Acres: Legal Description: 04 114 022 0.00 Sect-04 Twp-114 Range-022 10.00 AC P/O E1, Miscellaneous Information School District: Taxing District Code: Taxing District Name: 719 2005 PRIOR LAKE CITY Valuation & Tax Information http://www2.co.scott.mn.us/stellent/idcplg/records/pxs?IdcService=SC _PROPER TYT AX _ DET A... 2/14/2007 THAEMERT Septic Pumping P.O. Box 291 SHAKOPEE, MN 55379 / ~ ..~/... C\ L--\ '"'7 ) .~ \ / .-/ \.. . (DATE J / 7. L L/j) L-- (952) 496.2567 NUMBER II 81~ f eJ YV'4f.t. UG-f ,'.0 ~~ 1"-/.0 0 i) V v ~ t-' P i tl. C/-(? f) . V<!.... t, ( -t' vt<.. lih yV / - , Payment In Full Due Upon Receipt. Accounts Over 30 Days From Statemant Date, Subject To 1%% Per Month Finance Charga, Plus $20. Per Month Late Fee. TeRMS~ PLl;~SE DETACH .\f~O RETuRPIWITH 'tOUR REJ.'ITT.u:CE DATE CHARGES AND CREDITS pc) I! . V, () ~LJ{ v' BALANCE FORWARD j '7 /.2,-./ / 0 lJI Pump Septic Tank(s) ..2.) ."/ / I. v/<.. ) , j ~ . ' I .~' . 1 ~ - .)... -< I~ ~ I ;;,85<J J- ~8~'1 I-k......-!!. R;Ll..~C r lL:'.IlJLJ, ./1 ,k:~1 ~4, ,yt) ').. Y 1- Ii (L S' o K JilL 23 '06 ~ - C\?-~/ ' . .r. o\.v -:---J}:.J / :~;;;~':t~~,~, ~'~'-~.~P1 ~ ~,~_o_,r-~ J ~-, ., Ii \\ .~', (~ L'_:'~'C .I,J ._1.- ~-;;~t"'>U -.--'- ' \ ,------' :-.Y \ ~.e!ID.it..Fee-. ._~-,. ~0 Jii$po~al-ree--- ~V C: ~\I\A) t' g ,. THAEMERT SEPTIC PUMPING (952) 496-2567 (U" )lvJ I I I r. 'I,. ... .'. ..-\~.' ~~ - "".J ~j . . ".: . ;';.'.I':'~-' . qft ( D f. I I I I I I Total I vtk~cy(fU; s BALANCE 1 ,- I I I , .,k I\~.I..'." f' PAY LAST AMOUNT IN THIS COLUMN ) j , THAEMERT Septic Pumping P.O. Box 291 SHAKOPEE, MN 55379 (DATE 0' I-sJ 0 & l NUMB~ ,-. '\ / (952) 496.2567 t/~,' ~ CN'5f/L, 1'io!J-!1 '\{e{f- 81 (), C- ~ Yl(l)C:vt~, JI11N (r!JJ bit ~ ~YJ'I TERMS. Payment In Full Due Upon Receipt, Accounts Over 30 Days From Statement Date, Subject To 1%% Per Month Finance Charge. Plus $20. Per Month Late Fee. PLEASE DETACH M~D ;:U;:Tunr~ WITH-"OUR RE~"lrr"'~CE s- DATE CHARGES AND CREDITS BALANCE BALANCE FORWARD ~ L. ) Pump S!!ptic Tank(s) J ~Ip \) Thl.N\I.( - f'0i1:yt1 I / fR L/ I I r~M ~f:.-t: I $Ep h 'I f) /l "'_ L v - I "~ FI':'J ') "'1~' _ 1 t. I . ,,1,._ 1'ft~;:: 11 d .(51N" e' "(' '(\'QIS,.-'\~'r-' i~ 'f7 1'-"-:' :i(~ v! I ';CI r\'-'" _ ..' -: '1.0v;:' ti\ hJ 0 \) 'Y.'- ~. "nl i-"I.,.J ~ .~~ -\\'t\~ l: ~ ; 1 .-1 "" Ie. \ rr.--- : -- Permit Fee \ '-.. -j DlliPosal Fee \ f "",r) J --) Iv'.) p.,j ,,,,,:- / ",? ~~ ~otJl J'y Total THAEMERT SEPTIC PUMPING (952) 496-2567 ~~ ...... PAY LAST AMOUNT itUJ IN THIS COLUMN ...._-=.:-~~~=o.....-_- "",_"'r,"(,".~- _".._,~~;!;.o":.i:m':'~T\"..~!:..r,.,~'~:.,,"'J,\.t'.~\..h'" .~'.." . ~ '":. ,- ....... ':.~,-~,.lt:', .r.:.~~~~~~1t...~..,,.~.i...r.I:~;r.~ ,'~~~.~ 'l.'__~'~'" "7"'~.:~~~ '.'- .... ~~..~......~.~'*!':'\"t~""""""':':"'1.~~.!~.~~~t~:~.:,,,-...:..,...-.- .\'\{'r........-....7'""'..~:~.....~';.oI\~;~t;;i;'\"{.Y',:..;,.~:P.'r":',.'}"":.":.~.'~~~q SCOTT COUNTY, MINNESOTA Permit # '; g 11.58 INDIVIDUA~ SEWAGE TREATMENT SYSTEM (ISTS) PUMPING PERM!~ nil Owner \/ t., t- C!...{J ,^'CI-12 . Address fill ffLJD~ LA-J--fb Pumper ~.0( ~V1I1..tr1-t- No. of Tanks Pumped -Z..... Total Gallons Pumped Jz 0 U Check all that apply: 'Et Residential 0 Commercial o Rental ~. Scptic 0 I Iolding 0 Pump Chamber 0 Cesspool 0 Abandoned 0 Other:. Condition of Baffles (haffle~ mu~t he in~pectcd) 0 Acceptable 0 Unacceptable 0 Replaced Bafflcs ..., ,"-',,- /"', i i.N)'" if > '-' )~ 'J! If. / I-~(,,\....,.;) ;L [(t 1)( Depth of sludge layer Disposal Location (be specific) inches v4LA~ i~II~, fZJ. ;JvJ Did you observe a surface discharge? 0 Yes 0 No Pumped From: 0 Maintenance Hole .~ Removed Tank Lid (stavc, lor example) 0 Inspection Pipe (sec below) I have becn informed about the correct tank cleaning procedures and understand that I risk having my system failprcmaturcIy iUhe tank is not pumped through the Maintenance Hole / Tank Lid to cnahIe thc removal of solid~. D../'\ t'- !bLl'( , I f!-JvV";"~ L..t-. Sign~ture of Owner / Owner's Agent Reason for not pumping through the Maintenance Hole / Tank Lid Comments ~ (A^^^- () -+-n (i )NA/vI-.'1~'---1'-.---'rA-'-'----- , Pumper /Inspector Signatu;e. - \!I(:::':~1\ /\J "')"111~~ Date -7/ L- , ) f) 14 '\ ;'J - V '--.--.. " ~ , . Only one permit is needed per ISTS. If therc is more than one ISTS on a property. submit a ~eparate pcrmit for each ISTS. Submit a permit whenevcr a tank i~ pumped for ahandonment. Pumping the tank does not constitute a compliance inspcction. (2 vl. V:^!' ~/ L~<b: I White - County :11. ._\~ :' ". '" r'; , 1 CanarY - Homeowner .I " Pink - Pumper FormU1120 __FROM :DON STODOLAWELL ~RLG CO. ~ INC. FAX NO. :952446967121 ., i . Aug. 15 21211216 1219:1217At1 P4 AUG-14-2006 11:1121 ~MN DEPJ OF HEALTH: . I 51217 285 '(44::;' r'.~.L/IClJ. . ~ Sl-ad~l~ We..ll ~)\~ i Qr;2./ ~J/h-rri:/7{) , . Wf....OlIUtllllNiILOCATlOfl l ; MI~4DT"DEl'A1UM~OFHEAI.TH tNl"~wtUlndBoIlnII H n:", nnt"l"7.. ~"Imu ,'~ 'EL~ AND BORING S~LlNG RECORD =:':':urik!u8 Wal NIl. ~, 8 7 ~. ~. Ii . Mfntlft#8./flufn. D~'03I f!~("II\ti , 'oJ" .':1---. ~. ,~~.~. '~No.~~'No. f1VY.A 'Date8a1ll!l.'. . o.;"';'~............ - "" " ~ u..LY ~~. If' ~"ay. 64 .1- q.... 0 b ?f"*" 7-tf'}. U OP& . 1.dlullIUu~_~':n..f.U.,ooondf, ~Oa!t!"1loIIIt1:r 1-1 '7 ~ll OI!pII~",J J 7 l.CCl~ LoNtIUl!lIill_'"' ~ '1, 'IIIIlIII1'IIJi.CIllCll .0. '" , Il) 11I"1'ICW~LliVll.- N~"..rl(;Q18"OIlAddrd401flt'llNU/llW...sQl"llIWtI or""'DlI~ ,. .'il..,toqUilQr~~~llor ,.. 8 7~ I:iI:!::' l.-d IV w :'_'C.... 0......... .,Jla;::: I:) ~ SIlttIf8lllllt ~~y~ .', ....! ftldllIlIPaI"IIllIor~ Q , J .. ItIIlll\lO!Iollllvd\t>.~~ '... ' ,,~.. :afQft,'~D19"'1't C31lll'<.~"'. 001111" . f~ _",,10'11 CAba\lalal1ch"Jtt4D11 ... 1Ij$ ~ .r#' '" (. o..MU'.~W\lII>l CQH.l1'lK(S) . t- "j I': v",. ; ..+."..!.'.\..~... "r";' . , ..... I -\-1-' ~""" 'ill.;' .Sflllll.OPllllMl aWl CJDIl're' " I'K I,~~... .. w ..t....~.. "dOl ..,- e ',... ' "nUll!Anc>>MPl..r;tlClll <;. - - ~ 1 ' Ou\"" 0 wtllKo\IMI ....+-. ...1.1"..,.......... f . + _ _ --l-- 1l1li.ll:~: .. ~ilJaal AdIillIlIUn.' :r: -;"' .+' "1'" 1 . 3( ~i J;J Wellpa ~ "~ +~M':to. :Oll<llltd ,*,~~~II~N.w. ' :::~l : ~'1fI..~...o_~~1;:~~- J,#o in.llOm D OIJ~Ih~Il, '1'63", ~(;~.' -n~) '11"1<\; J ~ S" Lf. J :' Wiil'\.~R'8H^Mf/JCOMp.wfNA~~ );1'171.' W""OI'//""f....lolft\lN\Olll..~.._\hJrI ~~_ .. It- . PimllJl)1'lOtlll " ~. : 3! .; AN 200~ . AildSIOtQP PI". 0 t1ItlW: WIVe!') 0 Dobtls D FIll 0 No 0t>IifnIc8<<l ;, ~ Rf;:EIVEO: 'fvpe"'Cm~,1I""&II"bll).~-~'I- ~ ~ ~ . 'GIOl.OacA\,~'I1IIUA~'I~~~-II~ O\:lSllIllllllll1Slonlaved? 1I'i48 aNa O~IIIIlI--~ ~. . ..~ !lI4l._.~lI"'lIllIIfj"",,"'.III/ll\lm"'~!~..., PUMP ~ ~ ~:. : .' 0 '-It.f ~~nYeil [J N;"toIlBm (JOIrlGr ~ ::' 'J" tt UEritOIl U8iDTO lIJaI.~WJllI U1Wf:l!N I ~Ml1$; on tWllf(1l ~NlIlltIfI.IIQLI!: ~: 'I-~ J.. M~ "i' lib Cl NOI'.ID.Mi8paC6ExJ&tll II Ml'JIW~llOl!'IIlU\~IlIIh"JmlilpC' 0 llal~PorlOr.lllo/llftamoY1ll ~ r~'-- ~.. - in.1rom to' II. [J "pllomlfld IJ Removed . lJ ; .' ---. Uo ..1K2. JJtJ-~: .' ,'!~ J3S' ,.~ _. __I' Typo 01 p.~oralor --., :'1.. """"''0''' ..::-'"' : , 3 r " '1 y .' }~ -~. ~ !' __. .l~ &. [J Olh~' : " ' CRQUTlHG IIAlEllIA\'(&1 (ONI '*' of...-,. ta Ibo" Ont ""G at bII!1ton.... I/O lilt,) . . "\.1... ~ ~ .J _ A~ JJ . : Gmul!ft.M.z.riAl ~ ~,frq/T' .' to t&~ 'l\Yn,C? ",~J?lt. .. :~ . It. -- r _ul;f1llool .---" 1"'" CJ Ba8llJ!lll"'OIIac' o Wt' Pil rJ Durim! . . . ! em In onnUlI ho\lt .VIiIl IJNa ~"""JI.pa!lllllllll1t~y urOlllQl.\? . YOf 0 No (J Un~ in. from to .11. ovu 0"" C'lVlllI C1Nl1 OIJ~ In. f((lll'l (0_ .. It C1 v... CJHI1 !:JVn CIllo o~ IICREgwi'ft 1I0lJ! . ~roQnf~m:"'/ t- 10_'" J ~ll. OllllnHal.fro",_ \'P_ ft. . In. 110M . to fl. 1:1 Perlol",Od Cl AlImlN9G Q. yAlll& MQB v~. 8 ~ bIOS l/OtlI ' ,10 . II. Y411:h bag1 l: cmtI!hWIlWlAl108O/U>>ClS' 'RfiWlIlIJ,,~~~~~l1;::J:~ . -~'UlIr.:,alIil8f\d~~UI811IOl.orllCllrr'JDI1prop1IlY9 a ~n . No """,milly!", ...... .. ~ , '. ,~ UCE/l'fIII!:IfJIlRlIOlSTlIlilJ)C{llf1'nAI!mlACllRtlltCAllOH ~ ...~~.,/ ~ "t~ ~ 'fttln.I'1tbailno_ratltdin _1\I4IIllo\lllltUlcll.~ lltJlllt. Qj\Ipl",.tnlf. TIlo rn(o",,'UQnCll!\lllnt'llfrI\1lI1~ rlljlOll \1 AiWU ~ 5"1" II '5".. x..:t.. ~ ~oW..d( ~ -....I~~~~r~~;u..-~ ,,~~. ~.~.~~ ~al'7t-J ~ It. ~ ~!~.. CMl1!f!/1X~NIIt>>O ~ r60,!1 I UCII1lSIorR8g{lJItuIlD1lNo. ......1'*~IJ~.,;...IIf",,. ~~ l-I/;.-Ob -- ~6~ ~:.."J ~.. A~IIR.,I1t"n"'IMsSign8rut'll . i D/llo MlflH. DeM Cll' HEAL1lt;~ :: \ H 24;2927 Jrt~:m~ntJe~~ : ,. . ,~"" II. FRGM :DON STODOLAWELL DRLG CO., INC. FAX NO. :9524469670 MINNESOTA DEPARTM&:iNT OF ~r;^LTH WEll AND BORING SEALING RECORD S cot t Mfnnello/s SIIlIIlIBS, Chap/fir 1031 It>wn:lhil' Heme IT6W/l$h1p ti.iO: f1sn(JO No. Secllun No.IFrMll<H\ (em )0 10) OllIe Suclod _ Prior L~1ce 1.4 ~2 O~ ~ ." .... -211 l/OW 0& (IPS UIllUCle llegrAnt _ ._ ",illulee eeoond.. ~~? f LOCATION; P<\plll Beforo S"Lng -, .10;: _ lUf,g:!Ulhl <leur'" _. _triA"IOa 88001\""_ ~UlI'ER(81 tlun\Qllcal SlIlllll N:Jd(6eIl (if File NumD'l/ IllIG Cily 01 WuU 0/ Sorlno LooaUon S~~e AquffM 0 Mulw'lUilltf '.s\J.iDORlNG ?A"J) U"';1~ Rid.g.o-.Rd ~W (\f)r~~orSUllplyWIIU tJ Monll,Wcll 5ho'i1 n"ntlIO<:<!\\IorInIWll~ orbo(,n<J Sl<n~, map nf wnl (l(tiOrlno III ICellon grid with 'X' ~llnn. olIOY.lng property EI'lV. BOI" Huio 0 i)dltlf ~ N ," -lV 1l$$1~0ll~ M~ Il\Ilkfi1lO'l. CASING TVPf(8) I . ; . I . . ,j"~" ",..."!".. "T"' ..t.. 0 I ,.."'" w'Olool (ll'ltlAtio (.l TIle OOlhet -r-1 .1- tJo1:..' I " W "'j" ..+.,.. 1.., ...'... Ii 1- - i':)- WIlLlHIlAOCOMPl6'JION -j-o -1-1' -- T ..+.. .. !..... .... .... ...J i . + -i - >>- .. j... ..-l-.. '1--- "1". J . . . --L--L--'; I t'-._,~,,-+ [~IZ ,-" /(J- I"ROPFRTV OWNEfl'R 'MMEIOOMlWlY NAMF. 1- .J!e:i. t &._.r.QJ'!lP,tln..Y....... , I'~rty _'lM))l\leddl_lid'~n _lOOOIlnn .udl~tA I~.d tIt<'Ml WILL OR BONWG lOCAnON '.auIIIY llMlo OI.lI81de: 0 Well 11<<'$" ~f"UO$' IIdnple!llltil o wnn Pil o BIlned CASING(6) .. i1"II ' ,. hI. ImOll) Aug. 15 2006 09:07AM P3 Minnesota Wolland Ballog H I') r:: f\ ~ r: 1 Sealing No. I .:..:....t.:...1.J.U..O.'J- Mlnnelrola Unique Wo I No. ~!...~r,aa~' O/lln Wen (I( (lnMII C<<',elfllc!tlU ft. Ofl{Jinat ~lll STATIC WA1"'" lEVEL ,_It Jfl IJAUUr&J! LJ Eedm~llld _ L~h. ~l'lnW o .bomlSM eurtn"" InSlll.' 0 lluoomenlOff",,1 o Well I'll oeurin<! (lol~1l , IO$~, Rd in overe"" J1i1I&'{ (J YI>$ ~o Mnult\r "1"." inlUally ~rnlll.d? o Yes. rJ No tl Unknn'M' aOREl!N1oPl!N HOLE t , SCfBBllfrnm_S~ 10 .8S!1.. fl. Open Huto Imm, ' OBSTRUCTIONS )( Rods/Dil)P Pipe l. I Chenk Valvo(s) 0 Debris 0 l'IlI 0 No Ohalrut;lJon Tvpe 01 Ob!JlrucIiClll$ (rJesClibe) ~N:!JtIt. .~ .,.. p~ aI!OLOGICAI.MATE~~COl.OA l~~:~~~RIFROMI.~ .OllstRlctionsremnvBd? ~Ila 0 Nn Describe. ,--.'- ~d~""'''''''''''_M'''_.- A &:1 ';:~p Pome , , . ._.l..oL . ~ RemOVe" 0 Not Presont 0 Other_ IdETl<<lD uSIlO TO SEAl...4"NULAR 5P'-'~; aETWI\ENicAslNOll.on OI\$INO AtlD 1I0111'! HOll!! )(NI)Anll<Jlit 81lM" Gxir.ta 0 Nlllu\ilr "flIIllIl {lrO\!lerl ""h Irani$ PII''' 0 c,,".~ PetiomllutVn'nlWIlI lo.lrnm ..' 10 _. ' It. 0 l'orfolulCld rJ Rllmoved 14000 Veit Place Rogers, Mn 55374 _ _In.lrom_ ._In_ _ft. _'_ 1I1.lrom . p 0.11..J.~'" b- iii U.1.L.. W&Ll.OWNFA'S NAMe/COMPANY NMlI: WOi"V.,l8("A fllJl'llll1 "d\I(O>.\ ~ cHf'N1~ IhlIn p,.illllY (A"orc ~Jd(1lAA 'llIlkUl.... ~ ._ In. florn Type f,f pnrtoratnr _ o 01110'_ [.J Vaa 01\16 oYel DNa o UIlMown 10 ._11. oY"" ONn oy,,. o Nn o I)nklll'''''''' to __II. _'0 _fro o f'erlurt:lICcl 0 Removed GROUllliO l.lATIlIlIA\,,($) (O"t ben c>> e,,,,elll '" 94,b... 01191>89 I>f "'tonlle ., 50 lb..) erM"!1 ~IAIerlPJIlJaIJ1: (J&~(Jm_(:J_IO ..8S!JfI Yiltd, 33- barft ,'''",_ .. tu_ _ 11. _ ._ y8((!l> MtI" "..01_ ..1,,_ _Il _ _ yaIID "''''-''' onlER WELLS AllO DOlll/jOG Ol~"" wMlllled nl.I..1Um wnll '" bOdnfl on l"'rpillly'1 0 Yel 'f( No How Illllny? Llcliltl;eo on naOI$TliREO COliTRACTOR CJ;RTIFICAT10N . TIl,. 'lioll or bollnll Via.,iIlttWln or.nulIJ.,llC& I'lli!> MlllllolIo)IlIM"" Ch&plet 4126. TIle Inwm~\ion C<<,lo,nnd illll1ls /Qp<).1 I.. Inll! to Ule bOOI "I IIII' ~IlcJ'" RIl"ARKS, llOUflCli OF DArA, DlflFlCULllES IN seALING ~ 1)'1' Tn"',-1...6.9.1 Uc,'eIlSC or RIJ{Jill/mlion NO. MINN. OEf'T OF HEALTH COI'Y H 250651 NIlII/(J of P/lrsoo sonllng Ws" cr 80rlng .I'J ~~.s - o!c, . Dato ~~ 1?h121 FRCM :DON STODOLAWELL DRLG CO. I INC. WIll.l. 011 OOlllUO 1.00l.'l1011 COUllIy NII.1e .' FAX NO. :95244696713 Rug. 15 21306 09: 06Ar'l P2 / jl,\r.)\) tJ. be.." UO\AI(}rJ. ~~\((. R~. ''', pi';\\' MINNE~~ ~:~ARTMENT OF HEALTH Mlnne&ota Well and Boring H n I:' n ('::' ~ of) WELL A",O BORING SEALING RECORD t~::;o:unlque well No. _..t::.a.U--O-D~ / MlnnBSota StBtUlos. Chaprof t031 ~~~~l.~' 'IOIon'~.lIP 1\'0. I Raiiii9'No: s'" N>1fr'lllUon (em ....10) DAle SeIllod O'lll we~ Of oonng C<>nalructOII Prior L~ke 'q4 2l /041 ,. ." ~ p:'J: ':2Z.- (TtJJ.Y .~ GPS ltltlllldil dfgrO$.'< In>iolUlo. _. . a.""nda . I t.J It ' LOOATlou: --C' OOJl"'Blllor. S.a'llll. ,~- -II. Orig.>al oepln_ _ lOfl9\I~de..-;:-1I6ll!9!!~","";=n'JlIlIIn:--_~nds ,~A:R(8) S'fATlCWA'fllA LEVlSl- N......../lI"Alll:ltsal Ad<l'~~O Gr F1ro...l'Jlm'.lier lII.d ClIy 01 Wel or Roritlg l(lt'.n!iun",. _ 6lngle Aquirer 0 t.\li~aljllllaf . ./ :. _ A MIiuJ80R1NG J "~lfiI~~~\J'\Vn'nrSUPPiYW" D M""a,woil SI\<>1/ 1)l",CI ~1i"1l Of Well nr boilll\l Sl<otch mall 01 well \If bori~, ""'" ltI..,CU<lllllritl wtlll"lC' IOeaIf<m.lll1aMnlll."', . .;, 0 Fnv.l\oru HI~O 0 O'.l1or_ "'~. fl""", rflllM:'Jll<ll:r\Jl~g$, . CA$IIIG lYPI!(S) ;---~- i . ~".-- .'<.wm.._.~H_" <'.,_.,,"'_.-,-"-<._~' '-r' --t.. ..in.. 1-- ,. I l r w J...~.. "1'\"i" E .~t=- =;~. :-T:t+ $ ~Tml~ ,.1-" ..+ .. ..... i-- 1 ! : ;_41 '. ~..~.....-+ PROPI:I\TY oV/Nal'~ NMleiOOMPAt/y NAME ~eJt & GomQAnV . PttlpO.t, 0\\"""" mdJ1!) AJ1cYoUl , dIIA.nrJ 1hAn..........1)(><I nc!ck....lrodloolo<l ~ ~~'" Scott 1bwoon'f) NlIIM _fl. ~'II.,e61100 0 E6Iim.led f -'-~II. ~1Ili<lW U loov. t.al10 5\lrlnce ~ .:f . ~ln61 0 Pl6allO L1 lYa OOnlsr_. WEl-UlEAD eOLlPLfi1tON Ou181110' 0 We. H.ueo )(PilIeu ArloplOi'/Ur>i1 1...ld8' 0 R.~&emO(lt OHA~I r1 Well pa K~~ IJ \'loll I'll DOUMO n tlur~"l CA9jjjC(s1 - . O~rja" 0 I Oepln t _~ in. 1(01)>_ _ lo1.e!! 11. Sot lJ\ QVllt!Jil& IIdn? o Vnr. )(No 1u,1!Ular 4pnr:u llmi\lliv 9.auled? o YllS 0 uo 0 tln'"",,,,n 14000 Veit Place Roge~s, MN 55374 _'_ In.lrotn__ 10_. _ft. Dr€<> ON" o Yl!~ 0 'l~ 0 Un:<oowo _._ ill. from. _ tu ft. P Yll~ 0 N() o '1'08 [111I0 [1 Unknown WOi ';"',IS(6 m11~ lIdd".....11 uil!6I,nI i"nn pI\IllOlI't I'M""'" aMl...I_r.~ o!....'" $CRllEIIIOl'EN HO~1i. , f SerRan from.lS~ to I..M... .11. Opalll-lol~ from OBSTRUCTIONS ')( Rod~DIO" Plpt\ 0 Cl1eck VlI\Vo(C) 0 oehltu II RII [I No Ob~OCllon 'rypa of Ob~lructiol\$ (Dll6CIlb<))~~"" 1'f.J!!!(2. GEOLOGICAL h1ATllAIAL I COLOR I~~~=~~RI FROIA I TO c)\)8INCUOn.Q removo<l? ")lYO$ 0 NO Oe~clibe.._ .-. .-. l PUMP:a f1 ~".lllli""'\' .._....!WIII"11on loA IliHll ".."by I'If1 nl tofrill . :50 Lt::u Q J--J..;d'.. . ._ 0 Iii ~emovAd 0 ~111 oomor (T /,IllTHOD IIl1110 TO SMl ANtlULMI GPACE 1I1!T\VEEN 2 OJISIUGS. OR CASING ;'iii"ilOfll: HOLE, ~I'> AMIl.1r GpIlf,>) 1:'):"'0. 0 AM.tar sp..n gIOUlO(I V\;'1I lIente pl,., 0 C.lring pelf"",uOOIRomnv;1I hI. Irom _ II) _ ._11. 0 Pllrlotl:llCd 0 RelllOvetl _Iil_. . II. wm OWNER'S NAMF.JCOMI'ANY.NMlE Pof;JM-45247 _In.f((Jtl\_ II) It. o PRrlomlu(1 0 Romnvad Typu 01 perforator __ o OII1Af. . OROUTt/tO tlATERIAI.(S) (on& bllllllf cement '" ~4Ibe" onn beg of bJ'lonllo '" sO Ib!.) t;ml1tiU9M9\9rin~~rn" t!:) InL..J})'2n. _ ._ yaro. I~ hag$ _ Irom. -I~. . n. _ yl<ldl..- bon" 1n.1tl\_ _10_. .__IL. 'tllnlf, _. - bags OTliEfl WELLS AND BORIIiO$ O~191_.n1t<l3l1dllnu,,>dWO'J9rhtvin(lonplOl""Iy'1 0 y". *" HOW",,"'y1_ L1CE//SliP OR REGlll'fEREO conTRACTOR QIlRTIFICATrOIl Thit V."&:I nrburtl".(l Wi\n n::.':;:.!&(S n .t'r.~tlrdanCIJ vAil', M,m~&Otn Rut9s. Ohnsth:r .1720. Tlu: i1~torml1tiuu eontrJlloo ill \1119. ff/l;pclt i:'; '"1<1 lu 1M Il"'" "I my Kqn.A.....~o. R~M^H1(8, SOURce OF D^TA. fll~I'lCUf..1'tlt8ll1ll11,.lItlQ ..Wt:tll Co.,. It)c. ..lJi5!l. UC<ln!l8 Of RonistlH/iOIl No. 7~;)5- db . DRlo ~ 'A' MINN. OEPT or: IIEAlnl COPY I H 250 6 5 3 ~ Nllnm of PetS011 SPoRting well O( Bari,,;' 0 I?JO:;