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Home My WebLink AboutUtility Connection Permit 10-0445 DATE TIIIAE CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED ADDRESS ✓ �SIfJ � �i V� hOC[GC OWNER.,�yl'Featcr �t�2(t,�,v�. CONTR. PHONE NO. PERMIT NO. �� U�� ❑ FOOTING ❑ PLUMBING RI ❑ EX/GRAD/FILLING ❑ FOUNDATiON ❑ MECH RI O COMPLAINT ❑ FRAMING ❑ WATER HOOKUP ❑ FIREPLACE RI ❑ INSULA710N ❑ SEWER HOOKUP ❑ FIREPLACE FINAI �'FINAL ❑ PLUMBING FINAL O GASLINE AIR TST ❑ SITE INSPECTION ❑ MECH FINAL ❑ COMMENTS: � �. � WORK SATISFACTORY, PROCEED ❑ CORRECT AC ION AND PROCEED ❑ CORRE WO K, CALL FOR REINSPECTION BEFORE COVERING Inspector: OwnedContr. CALL -9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTSARE FOR YOUR PERSONAL HEALTH dc SAFETY! LvsNOn OATE TIIAE CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED �. ADDRESS 5 G �7ld 1�?''PD�9� 1`1.�1�Q_�` 1"�%`- OWNER CONTR. PHONE NO. PERMIT NO. ❑ FOOTING �B'�LUMBfNG RI O EXJGRAD/FILLING ❑ FOUNDATION ❑ MECH RI ❑ COMPLAINT O FRAMING � WATER HOOKUP � FIREPLACE RI ❑ INSULATION ❑ SEWER HOOKUP � FIREPIACE FINAL ❑ FINAL O PLUMBING FIMAL O GASLINE AIR TST ❑ SITE INSPECTION ❑ MEGH FINAL 0 COMMENTS: � � .L�`�.�'e f a-- C '' � �� 1-- o_t - � ! -o.g,�� 1 2 � �`1 - 0 WORK SATISF CTORY, PROCEED ❑ CORREC ACTI N AND PROCEED CORRE T WO ALL FOR REINSPECTION BEFORE COVERING Inspector OwneNContr. CA 98 � R THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE R REMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY! �xsxor, DATE TIME ` GITY OP PRIOR LAKE � � 'T" INSPECTION NOTICE SCHEDULED �J ADDRESS �j �QjCp_��pQ(I,� �ilf'�J I�C OWNER CONTR. PHONE NO. PERMIT NO. J 6,. U L�5 ❑ FOOTING ❑ PLUMBING RI ❑ FJVGRAD/FILLING ❑ FOUNDATION ❑ MECH RI ❑ COMPLAINT ❑ FRAMING � WATER F{OOKUP 0 FIREPLACE RI ❑ INSULATION �SEWER HOOKUP ❑ FIREPLACE FINAL ❑ FINAL ❑ PLUMBING FINAL � GASLINE AIR TST ❑ SITE INSPECTION ❑ MECH FINAL ❑ COMMENTS: � � , P� „�� i; e5 , ��, I � ❑ WORK SAT(SF TORY, PROCEED � CORREC N AND PROCEED ❑ CORR T K, C LL FOR REINSPECTION BEFORE COVERING Inspecto : OwnedContr: CALL 447-9 FOR 7HE NEXT IIYSPECTION 24 HOt1RS IN ADVANCE. CODE REQUIREMENTSARE FOR YOUR PERSONAL HEALTH & SAFETY! uvsnor, DATE TINE CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED � �� ADQRESS �� Q ��?e�wy 1� i V�Qf � �( " OWNER CONTR. PHONE NO. PERMfT NO. �O ^ L` � ❑ FOOTING ❑ PLUMBING RI ❑ EX/GRAD/FILLING ❑ FOUNDATION O MECH RI ❑ COMPLAINT ❑ FRAMiNG i� WA7ER HOOKUP ❑ FIREPLACE RI ❑ INSULATION 0 SEWER HOOKUP ❑ FIREPLACE FINAL ❑ FINAL ❑ PLUMBING FINAL ❑ GASLINE AIR TST �.SITE INSPECTION ❑ MECH FINAL ❑ COMMENTS: ❑ WORK SATISFACTORY, PROCEED �CORRECT ACTION AND PROCEED _� ❑ CORR RK, CALL FOR REINSPECTION BEFORE COVERING I ns Owner/Contr: CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTSARE FOR YOUR PERSONAL HEALTH � SAFETY! INSNOTI DATE TOAE CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED � ADDRESS � �p ��Xn� �,`�r' F�J� r OWNER CONTR. PHONE NO. PERMfT NO. �� " �� _ _ ❑ FOOTING ❑ PIUMBING RI ❑ EX/GRADiFILLING ❑ FOUNDATION O MECH RI 0 COMPLAINT ❑ FRAMING RT"WATER HOOKUP ❑ FtREPLACE RI ❑ INSULATION �EWER HOOKUP ❑ FIREPLACE FINAL O FINAL ❑ PLUMBING FINAL O GASLINE AIR TST ❑ SiTE INSPECTION ❑ MECH FINAL ❑ COMMENTS: � � J❑ WORK SATI C70RY, PROCEED ❑ CORREC AC ION AND PROCEED ❑ CORR T K, CALL FOR REINSPECTION BEFORE COYERING Inspector OwnedContr: CA 9850 FOR THE NEXT INSPECTIQN 24 HOURS IN ADVANCE. E REQUIREMENTSARE FOR YOUR PERSONAL HEAZTH & SAFETY! uvsvorr DATE TIYE CITY OF PRIOR LAKE INSPECTION NOTICE SCHEDULED ADDRESS �7,81,.� C..TeDCV� Q1,�`IAQ.r"� �( OWNER CONTR. PHONE NO. PERMIT NO. «" y�� ❑ FOOTING ❑ PLUMBING RI ❑ EX/GRAD/FILLING ❑ FOUNDATION ❑ MECH RI 0 COMPlA1NT ❑ FRAMING ,8'WATER HOOKUP ❑ FIREPLACE RI ❑ INSULATION � EWER HOOKUP ❑ FIREPLACE FINAL ❑ FINAL ❑ PLUMBING FINAL 0 GASLiNE AIR TST ❑ SITE INSPECTtON ❑ MECH FINAL ❑ COMMENTS: �o�� Y ❑ WORK SATISFACTORY, PROCEED �CORRECT ACTION AND PROCEED ❑ CORR CT , CALL FOR REINSPECTION BEFORE COVERING Inspector OwnedContr: CAL 50 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE. CODE REQUIREMENTSARE FOR YOUR PERSONAL HEALTH & SAFETY! wsnor, oF PRtp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd TEMPORARY CERTIFICATE OF ZONING COMPLIANCE � . /v � _�°�` ; "'. � .. b �_�. ,� AND UTILITY CONNECTION PERMIT U "� t�j M�'�'NES��P � Wh��e File pERMIT NO. �� (��' 2 Pmk Cny 3 Yellow AppLcant Please e or rint and si at bottom) � ADDRESS ZONING (ott'ice use) 5 � a L� C 2�.�i i`Zz ��2 IZ� S E �R�aR �AS�E .�Mn\ LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID � db Sn�TEGRt��'EtE�,�� q�2-22t�- (Address) — f �o�� l., � � 0 R P►1�. 0� i. s.�L. t" 12 �. O(Z LA 1� r�� i vJNJ�S�'S1� •�-v5 �j"� 2. / . BUII..DER (Company Name) (Phone) (Contact Name) (Phone) (Address) TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing ❑Re-Siding ❑Lower Level F�msh ❑ F�replace ❑Addinon ❑Alteration ❑Utility Connecnon CODE: ❑I.R.C. [`�]I.B.C. ❑ M�sc. �L�w�l C�cJ,e�'-t—� ( � 1<v � Type of Constiuction: I II III IV V A B Occupancy Group: A B E F H I M R S U PROJECT COST/VALLTE $ Division: 1 2 3 4 5 (excluding land) I hereby certify that I have himtshed mformat�on on th�s apphcation which is ro the best of my knowledge true and correct. I also cerufy that I am the ownrr or authonzed agcnt for the above•m honed property and that all construcnon will conform to all existmg srnte and local laws and will proceed m accordance with submuted plans. I am aware that the buildmg offic� ca revoke ffiis permrt t cause Furthermore, I hereby agree that the ciry official or a designee may enter upon the property to perform necded mspectwns � x � - a�-ao 1 O Signature Contractor's License No. Date Permit Valuation Park Support Fee # $ ��'s��1�x . E $ oo � sac �oo #3 $ G3oo � $ �( � Water Meter Si 5/8 ; 1"; $ j o. . ' v ��: v N K $ ( 0 $ �� Pressure Reducer $ � - .' Penalty $ Sewer/Water Connection Fee�� # 3 $ 4 00. � 5 Plumbing Permit Fee $ _ � Water Tower Fee � pOD # 3 $ 3 0 00, ' Mechanical Permit Fee $ Builder's Deposit $ Sewer & Water Permit Fee $ Other $ Gas Fireplace Permit Fee $ TOTAL DUE $ This Ap n com Your BuilQing Permit Whe Appr ved Paid 2� U� ReC t No. S(o (� Date (� B � Zb Io Buddma C1tlicial Date Th�s u to cert�fy that the request m the above appLcat�on and accompanymg documents is m accordance w�th the C�ty Zonmg Ordmance and may proceed �.c requested Th�s document when signed by the City Planner conshtutcs a temporary Certtficate of Zomng compl�ance and allows construct�on to commence Before occupancy, a Ccruficam of Occupancy must be issued Planning Director Date Special Conditions, if any 24 hour notice for all inspections (952) 447-9$S0, fa� (9S2) 447-4245 4646 Dakota Street Prior Lake, MN 55372 � pRI� Date Rec'd � �� CITY OF PRIOR LAKE PLUMBING PERMIT �� ¢� �(� � x � � � 1 Blue F�le pERMIT NO . 2. Gold C�ty O • 3. Yellow Apphcan[ lease or ' t and si at bottom ADDRESS ZONING (oflfice use) �,�� '� I U�1� �L� LEGAL DESCRiPTION (office use only) LOT BLOCK ADDITION PID o�R 93� a �� 7 (Name) � (Phone) , (Address) (/ � � �,� Q APPLICANT �� L (Name) � (Phone) (Address) ��,� � �� L- . (Address) (City) (Zip Code) (Contact Person) ��%� +� (Phone) � �� — 3 � APPLICANT SIGNATURE DATE APPLICANT PLEASE COMPLETE BELOW Quanti T e of Fizture Quanti T e of Fizture Bath Tub with or without shower Rou h-ins Dishwasher Water Heater Floor Drain Water Softener Lavato Bathroom Sink Stand Pi e ashin Machine Laun Tra 1 or 2 com artment sink Sewa e E'ector Shower Stall Backflow Assembl Sinks Backflow Assembl Test Bar Sink Lawn S rinkler Water Closet Toilet Other FEE SCHEDULE Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50 Residential, Additions & Alterations . Estimated Cost $ Building Permit # � PLUMBING PERMIT FEE $ p� I� � STATE SURCHARGE $ . 0 � TOTAL PERMIT FEE $ � � � L/ �� (Office Use Only) This Ap ati ecomes Your Building Per t W n Approved Paid e . 7 O Date By uildin¢ O a 24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 O � rRjO� Date Rec'd � � CITY OF PRIOR LAKE � /�� /� � � SEWER AND WATER PERMIT � " '. �`ce" F'` pERMIT NO. 2. Yellow C�ty �O 3. Gold Applicant ease or ' t and si at bottom ADDRESS ZONING �o�ce „�� K/ � LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID OWNER � (Phone) ��C�c�.�'— �� » ame (Address) �E2 / � `U( b� � � � � `� �� ?9�N �� o� (Address) (City) (Zip Code) (NameCANT � � l� xj �L � (Phone) ,9�0� ,�7 �` ��[! V (Address) b � � �g � �"3 7,�- (Address) (City) (Zip Code) (Conta.ct Person) 4� �3 D� (Phone) �/� �I� ��,� APPLICANT SIGNATURE � DATE � � APPLICANT PLEASE OMPLETE BELOW Size of water service � inches. k��'B Location of any couplings from structure feet. Type of sewer pipe. ❑ ABC PVC ❑ Cast Iron Estimated length of sewer line � feet. Clean out (if required) located at feet from structure. FEE SCHEDULE Residential sewer and water line connection $51.50 Industrial, Com'1 & Multi-family 1% of job cost �' , m Sewer connection only $25.50 Water connection only $25.50 Estimated Cost $ Building Perxnit # SEWER AND WATER PERMIT FEE $ �� STATE SURCHARGE $ .50 TOTAL PERMIT FEE $ � U � (�/�-- (O�ce Use Only) This li'on Becomes Your Building Per 't W n Approved Paid Receipt No. 7 (� Date By Buildina Official Da e 24 hour notice for all inspections (952) 447-9850, fag (952) 447-4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 � Metropolitan Council ii Environmental Services May 25, 2010 Bob Hutchins Building Official City of Prior Lake 4646 Dakota Street SE Prior La1ce, MN 55372 Dear Mr. Hutchins: The Metropolitan Council Environmental Services (MCES) Division has determined SAC for the Integra Telecom located at 5786 Credit River Road SE within the City of Prior Lake. � This project should be charged 3 SAC Units, as determined below. t, SAC Units Charges: Office 1680 sq. ft. @ 2400 sq. ft./SAC Unit 0.70 Warehouse 15,120 sq. ft.�@ 7000�sq. ft./SAC Unit 2.16 Fixture Unit 8 f.u. @ 17 f.u./SAC Unit 0.47 Total Charge: 3.33 or 3 The business information was provided to MCES by the applicant at this time. It is the City's responsibility to substantiate the business use and size at the time of the final inspection. If there is a change in use or size, a redetermination will need to be made. If you have any questions, call me at 651-602-1118 or email karon.cappaert@metc.state.mn.us. Sincerel , �,' �a�� Karon Cappaert SAC Technician - Environmental Services Division KC:kb: 100525A4 Determination expiration: May 25, 2012 cc: J. Nye, MCES f � Chuck Elliott, Integra Telecom (ernail) � www. metrocouncil. org 390 Robert Street North • St. Paul, MN 55101-1805 •(651) 602-1005 • Fax (651) 602-1477 . TTY (651) 291-0904 Arz Equal Opportunity Employer �uo�- F ' ! Doc. No. A 783508 � OFFICE OF THE COUNTY RECORDER �� gCpTf COUNTY, MINNESOTA ° Certified Fled and/or Recorded on '� 09 at 03:28 Receipt: Q00000 . Pat 8oecla�n, �u�Y Recorder � Fee: $ 46 . (Reserved for Recording Purposes) EASEMENT AGREEMENT . TffiS AGREEMENT made tlus�day of 1��r u sf, 2007 by and belween Scott Rice Telephone Company (Integra), a Minnesota corporation, hereinafter xefezred to as "Grantox", and thc�C1TY OF PRIOR LAKE, a Minnesota Municipal Corporation organized under the laws oi' the State of Minnesota, the Grantee, hereinaRer referred to as "City." WITNESSETH: PERMANENT EASEMENT The Grantor, in consideration of the sum of One Dollar ($1.00) and the other good aad valuable consideration set forth below, the receipt and sufficiency of wluch is hereby aclrnowledged, do hereby grant aad convey to the City, its successors and assigus, forever, permanent easements for drainage and utility purposes, across, on, under and through land situated in the County of Scott, State of Minnesota, as described in attached Exhibit "A" which is incorporated herein as if fiilly set forth. INCLUDING the rights of the City, its contractors, agents, servants and assignees, to enter upon said easements at all reasonable times to construct, reconstruct, inspect, repair, and maintain said drainage and utility easements over, across, on, under, and thmugh the permanent easement, together with the right to grade, level, fill, drain, pave, aad excavate the easements, and the further right to remove trees, bushes, undergrowth, and other obstructions interfering with the location, conslruction, and maintenance of said easements. The Grantor's fence shall be permitted to be maintained in the easement. IN FURTHER CONSIDERATION of granting the easements, the Grantor requests that the City pmvide two sets of water and sewer service stubs for future connection. The Grantor will have one year from date of notification of service availability in writing from the City to connect the existing building to sewer and water stubs. Additionally the Grantor must abandon the existing well and septic system in accordance with Minnesota Deparhnent of Health and • Pollution Conh�ol Agency standazds within 6 months of the building connection. Prior to connection the Cnantor must apply for and receive a permit for connection. At the time of pernut issuance to the Grantor the sewer and water eactension, connection and hunk charges of $61,909.00 plus the water meter/inspection cost and $4,325.00 per SAC nnit as determined by the Met Council must be paid. The City agrees to defer the charges and fees for the second set of sewer and water stubs until the tix�e of'property subdavision or building permit issuance wluchevcr occurs first The fee basis for each set of connections is: Sewer and Water Extension Fee: $45,000.00 Sewer Tnmk Charge: 1.98 acres x$3,040 =$ 6,019.00 (1/2 of properiy less easement) Water Trunk Charge: 1.98 acres x$5,500 =$ 10.890.00 (1/2 of property less easement) � Total Estension & Trunk = $ 61,909.00 D1d:32T255 r � '�,([+J� , �S } F . Page 1 of 5 Q(, 49 � • Q�;�—�z.tC� � ✓IN sS37 � d , Sewer and Water Connection Charge: $4,325.00/5AC Unit* + Water Meter/ Inspection *For the existing and proposed buildings the Owner must submit a floor plan or building information to Met Council for Sewer Area Chazge (SAC) detenvinarion. Estimate numbers based on 2008 numbers aze subject to change per City Fee Schedule. 2008 SAC ESTIMATE: , $1825.00 MCES SAC (assumes $150 increase) _ $ 600.00 CitySAC $ 900.00 City WAC • , 1000.00 WaterTower s4,325.00 per SAC determination unit It is further agreed that in consideration of the Sewer and Water Extension Chazge paid as stipulated in trris agreement the City will not assess the Crrantor for futiue sewer and water . improvements. It is fvrther agreed thak the City at its cost will restore the existing property line to pro-pmject condition including replacement of the existing fence. During construction the City will temporarily relocate the existing fence to provide security to the Grantor's site. " The above named Grantor, for itself, its successors, heirs, and assigns does covenant with the City, its successors and assigns, that they aze well seized in fee title of the above described permanent easements and they have the sole right to grant and convey the easements to the City. IN TESTIMONY WHEREOF, the parties have signed this Agreement th� day and yeaz first written above. . ' ' GRANTOR: Scott Rice Telephone Compan,y�Integra) By / � � ' G�� STATE OF MIlVNESOTA ) . ) ss. COUNTY OF seoTr' ) The foregoing instxument was aclmowledged before me tlris t'7 i�._. day of AU��t� , 2007, by Scott Rice Telephone Compaay (Integra), by and on behalf of itself. DONALD MARVIN BARU►(iE �� N � �� Notazy Public Minnesota My Cannedan E�ue�.len 9f � 20f 0 GRANTEE: C1TY OF PRIOR i.AKR By o- � J k Haug - Its r DN: 327255 Page 2 of 5 � . SCOT'�' COUNTY, MINNESUTA Pe�rmit # � +� � � INDYVIDUAL SEWAGE TREATM�NT SYSTEM (IST�) FUMPING PERl1��'T Owner f Address �� C.-�/'�'v''r T.�-/ �/'�.f" ,, ,�� Pumper ��j„ �,,�, '� ' . �To. of Tanks Pumped _� Total Galio�s Pnmped /R �-. � C5 ' � Check all that appty: esidential �mmercial ❑Rental [�"'� ptic ❑ Holding ❑ Pump Chamber ❑ Cesspool ❑ Abandoned ❑ Other: Candition of Baffles (baffles rnust be inspected) ['�'Acceptable ❑ Uriacceptable ❑ Replaced�Baffies De�th of sludge layer �_ inches I3isposal Locatioa (be specific) �l b�t,tr l�/C.� IIid you observe a surface discharge? ❑ Yes � Pnmped From: [ 4 ]"1�1�ai�tenance Hole ❑ Removed Tank Lid (stave, for exatnple) ❑ Inspection Pipe (sea belovt�) I have been informed about the correct tank cleaning procedures and understand that I risk having my systexn fail p�ematur�ly if the tank is not pumped �hro�gh the Maintenance Hole / Tank Lid to enable �he rernoval of solids. , Signature of Owner / er's Agent Reason for no ping through the Maintena�ce Hole / Ta�k Lid Comments Pumper / Inspector Signature Date �- / � -/� Oitly one permit is needed per �STS. If there is more t an one I on a property, submit a separate permit for each IST$: Submit a permit whenever a tanlc is pumped for abandoninent. Pumping the tank does not constitute a cornpliance inspection. �T}►ite - GQUi�ty . C�nnar}± - Homeowner Pmk - Pumper ' wrm n�20 , , , .,F - - :��-_�':.I _ ` . . _ _ � 'f r:'�r:.�. -- ' " - - ,�.y.: ..'j ;�,^�- _:�+ �'�`'•:;' • { M . k` " ' N1INNESOTA DEPARTMENT OF HEALTH �lirne;o�a'Neil and Borny i ��` �� p� � , i WELL O R BCRING LOCATION � c2aling No I H Q �} !Gcuntyu me �/ WELL AND BORING SEALING RECORD N��nnesotaUniqueN/e'INo � � � j . ' .L6.- + tilinnesota Stafutes, Chapter 103I e�r W_ senes No i i � ( � { � , Tov.��sh�p �ame iTo�ro�sl'ip No Range No Section No Frachon (sm -� Ig ) Date Sealed Da+e LVell or Boring Constr ctzd � ,J, / � i� r , 't( L�a �e 1�__� 1 NU� .�i�S� 1 ! � � ' �/,�11cr✓�,u.�l/ I � GPS Latdude___ degrees____ minutes___ seconds DepfhBetoreSeaiing_[_�____ _. it Origir,alDepth_ � �__ __ft i LOCATION Longrt�de__ degrees____ minutes seconds AQUIFER(S) STATIC WATER LEVEL -� Numencai Sireet Address or Fire Number and Ciry of Well or Bonng Locatwn '�'uingle Aqwfer �^: fvtwtiaqwfer _ I S �7 f�/ _ `��' ,j �(, ( +� �� WELL/BORING � �t« Nteasured �j EsUmated Date Measured_ l�.� f � Water-Supply Well '� Monrt Well / � Show exact iocatwn of weli or bormg Sketch map of well or bonng -J Env Bore Hole L + Other �1 I ft � below ❑ above land surface in section gnd with 'X" locahon, showi�g properry - ----- hnes, roads, and bmldmgs N CASING TYPE(S) --'--- -- `-- --`-- ---'-- " � Steel ❑ Plastic I � Tde �' Other _ --1--- --1-•- ---`-- ---+-- WELLHEAD COMPLEIION W: : : ;E _ . � � � � Outslde: � Well House ❑ At Grade ' Inside: ❑ Basement Offset -- - - - - -- - -- �h Mne �' PrtIe55�AdapterNnd ❑ Buned ❑ Well Pit � � .... --.--- --r-- ---.-- - - � ❑ Buned Q Well PJt ' , S 1 , ❑ Other � t Mde � '�] Other � PROPERTY OWNE 'S NAME/COMPANY AME CASINCa(S) . ' G Diameter Depth Set in oversize hole? Annular space inroally grouted� P�operty owners mailing ress H diNerent than weq Iocallon eddress ind�cated above (/ �n. from to? � ft �] Yes ❑ No � Yes ❑ No ❑ UnknOWn —�-- y� �� r�� s� ,� . °�.` y� � in. from to ft ❑ Yes ❑ No �. Yes 0 No ❑ Unknown �i, �r lGt�f t�?Jv Y' � in trom�_ to n ❑ ves ❑ No [] ves ❑ No ❑ unknown WELL OWNER'S NAME/COtv1PANY NAME SCREEWOPEN H��E . Weil owners maihng address d difterent than property.ownefs address�indicated above �reen front��, to�_�ft Op2n Hole from �� _ t0 �� R oss�ycnONS °`, ; - . , . � � Roda%Drop Pipe ` �,Chede Valve(s) � Debns ❑ Fdl � No ObstrucUOn � ,� . l}+Pe of ObS�truCtlO�s (C�65C�)'�� -�— �—, •.,, - '� • � :` �; GEOLOGICAL MATERIAL COLOR ��p� � FROM TO �strucdons remoyed?. ❑ Yes ❑ No Descnbe If not known mdicate eshmated formation log irom nearby well or boring � p �� P J J ' (� Type S4t �.Y�1C/1'��-6 IL � � � � " Removed ❑ Nat Present ❑ Other �, � � � q�' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: �; � • � No Annular Space Exlst9 ❑ Annular Space Giouted with Tremie P�pe ❑ Casiog PeAotetion/Nemoval , � m. from to tt ❑ Perforated ❑ Removed ' in. from '•� ' to tt ❑ Perfarated Q Removed i � � • �Type oi Perforator _ _ " ❑ Other GROUTING MATERIAL(S) (One bag of cement = 94 Ibs., one bag of bentonfte = 50 iba.) , Grouting Material �� '�� from� to� ft yards_� bags � from ' to ft yartls bags from to fl.�_ yards bags ' OTHER WELLS AND BORINGS REMARKS, SOURCE OF DATA, DIPFICU4TIES IN SEALING Other unsealed and unused weil or bonng on property� [J Yes� No How many� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION � � ' This weN or bonng was sealed in accordance with MmneSOta Ru�es, Chapter 4725. The rnformation wntamed m this report is true to the best of my knowledge � �/ — �,Jrl� .S°/�1�� .�ix'. /� o / Contractor usiness Name ' L�cense or Registrahon No ' t�� 9 0 ;� a Cert/Ned Re sen a" " na Certlfied Ae . No � Date IMPORTANT-FILE W1TH PROPERTY H � y� / O J, \r/ Name ol Person Sea6n�l or B� �� PAPERu-WELL OWNER CQPY {J ( �� tr�l HE-01434-09 IC# 140-0423 ��6R �-g-2n�0 y � �- � �NT� �-� 7f�/ �C � �'1 � � � � 5`7a1� C��r �� 2 �d S� �� '� �- o `n � 3� � �� , �- �- s St�uToFF � �v�'T 3 ��T -to �� 53�� i � 2" ��s�� / �� 2 � �� -� ° � O a�N � S � W �T� 1 i N �. �C�ot`� �5t��.,�'o��' � T(-�� fi5 �---- 1 S�� E-Rarc� 4� �'O '��25� CI�Hr1aU� � s i'�` �{- �� C1�ANov�.� I So G�v,�.�D "a;eE p��E� ��Lj�Zi �o� I..oc�T ��tvvc,� ��.R�C S�. �� • �� ,,'` ��P��u� �a' a�o 22 z,�TO �t 3 ' ,� — 33 ��., ► 2 a. S c�� R; c,ti 4z�' ��Q� � �u1T�C.GtL�A � 2��5`��Fov�. c�o-v� a ��an � . .� Zza� 22 - i' R ��5 i � r ov� �Av�p i� � � -�' �_ �o� �� _ � ��e , d� ---' � I '� � ��b th � '� � � � 4��, r �rC1 1 ,� ` � � I L� �� _ � �� _ , �o '� r � ��, X � �, ' F � � � �'� � � �'�- '�' � � -� � �, � � ��