HomeMy WebLinkAboutUtility Connection 14.0201 y ❑ 0)4,,
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SCOTT COUNTY, MINNESOTA Permit# 35747
INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PUMPING PERMIT
Owner ( l 4 4 603 7A4- ✓fi J,=i Address I ) 2c) t 1 �}v
Pumper No. of Tanks Pumped y Total Gallons Pumped , 2>
Check all that apply: Residential ❑ Commercial ❑Rental
"J -Septic ❑ Holding n Pump Chamber n Cesspool n Abandoned ❑ Other:
Condition of Baffles (baffles must be inspected) [ cceptable l I Unacceptable ❑ Replaced Baffles
Depth of sludge lay ` / inches
Disposal Location (be specific) T/ ? 6 c
Did you observe a surface discharge? ❑ Yes 'No 1 '
Pumped From: ❑Maintenance Hole ❑ Removed Tank Lid(stave, for example) ❑ Inspection Pipe (see below)
I have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely
if the tank is not pumped through the Maintenance Hole/Tank Lido enable the removal of solids.
Signature of Owner/Owner's Agent Reason for not pumping through the Maintenance Hole/Tank Lid
Comments NO C-Y 'J t' C� fO �✓ ? ,�' �<
Pumper I Inspector Signature i i _ Ab, Date /1-t
Only one permit is needed per ISTS. If there i fore tha one ISTS on a property,submit a separate permit for each ISTS.
Submit a permit whenever a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection.
44
White County Canary-Homeowner Pink-Pumper X1120
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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 330321
WELL OR BORING LOCATION Sealing No.
County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No.
Minnesota Statutes.Chapter 1031 or W-series No.
sayit- . -
st`ru'ct.ewd
Q 1
Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed LI11n
pal � IYe 14hz_W/ f id 5W4 Date Well or Borin on
I J/26JI-� ' W
GPS LOCATION-- decimal degrees(to four decimal places) Jj��
Depth Before Sealing___...._.".,12,0 rt. Original Depth -_,-.-
It
Latitude LongitudeACW
---- --`-- STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location I Single Aquifer -,'Mulliaquifer �r j
�asured Estimated Date Measured.
�]7f� (� ,�J,, Ai...e. N kis ee WELL/BORING
17
� J` �}IA
4 yet !'vt. h�IY® ' Water-Supply Well Mond.Well I
Show exact location of well or boring SkeIh map ofwellor boring _Env.Bore Hole Other _ _ _._.1 ft �!'Celow above land surface
in section grid with"X:' showing property is
lines.roads,and buildings.N CASING TYPE(S)
-\--
- ..8teel ,- Plastic Tile' Other
.--;--" - -- WELLHEAD COMPLETION
•
w ' E Ai Grade Inside: WBasement Offset
Outside: Well House
Mile witless Adapter Unit Burled
'� Buried
$It - -
i i i i I WP11 Well PPitOther_—
-
-._-------- ___..
1-- —
mile I Other_
PROPERTY OWNER'SMEiCO PA Y NAME CASING(S)
-fs r? I 0.1 US J0''L, Diameter Depth Set in oversize hole? Annular space initially grouted"
Propertyownersoownersmailing address it dlffere I than well location address indicated above ' infram___CL_ to.31.1.ft. Yes No Yes No Unknown
in,fromto It. Yes No Yes i No 1 :.Unknown
infrom toft. .Yes No Yes No 'i ;Unknown
WELL OWNER'S NAME COMPANY NAME SCREEN/OPEN HOLE ^7 /
Screen from -._to ____ft. Open Hole from ,--( _.to -L:t-C.._.ft
Well owner's marling address it different than property owner's address indicated above
OBSTRUCTIONS
,iiiiiods Drop Pipe Check Valve(s) Debris Fill No Obstruction
Type of Obstructions(Describe)
HARSOR Obstructions removed" /res Na Describe__ _ _. ._ ____ - _ --- -
GEOLOGICAL MATERIAL COLOR FORMDNEATIONS
FROM TO - �-
PUMP
If not k/nyown,indicate estimated formation log from nearby well or boring. (�� Type ,� �I`} t_ i 01
464%__Ker
�t1' / ,njlt tE 0 -+l.J •''Removed ;Not Present I .Other
`r`tA`�(4 [ � 9 n �r METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
4I� � "ltfo Annular Space Exists Annular Space Grouted with Tremie Pipe Casing. Perforation Removal
j r\y Nue, in from to ft Perforated Removed
J -
30, +(lt 6ro"''• 1 5 Z45 n.from to ft. Perforated Removed
6l Thee 2-`5 °.
��; Type of Perforator .
f"A14,4_' t& r't 4P 1 _ bO VARIANCE
Cf4'1y v.w 1 ry,\( (
I ` �r�( y ?� ; t Was a variance granted from the MOH for this well" Yes No TN#
! GROUTING MATERIAL(S) jt (One baagg of cement=94 lbs.,one bag of bentonite=50 lbs.)
--- - - /111 r / (C_,T)f', / from � to 4 r7 ft ... ___ yards 35. bags
Grouting Material 4# t'{.. .. -- �-:'
from to ft... -.... yards-_- . bags
from to h. yards 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? _ _ __ ---
��1�,�ri/-y LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
V'v VI���� � . i.Jn/1 / J�3 This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The information contained in this report
V - !w� f is true to the best of my knowledge
LI:\.:)-,\.u.,,,,LD. 0445
Licensee Business Name License or Registration No.
_ a1 Y u/2r0p
Ceratted Represent, e Signature Certified Rep-No. Date
330321 w �e Gc' - - r i
IMPORTANT�ILE WITH PROPERTY H Name o/per orori Seating Well or 8�ung
PAPERS-WELL OWNER COPY -- —
HE-01434 14 IC#1 40-0423
Drilling Co. Invoice
Bohn Well
18190 Dairy Lane, Suite 101 Date Invoice #
Jordan, MN 55352 10/28/2015 25774
Bill To Ship To
Kerri Gustafson
17201 Sunset Ave NW
Shakopee, MN 55379
Job# ' . Terms 1 .Due Date
16400 Net 15 11/12/2015
Description Rate Amount
Qty 10.20.15 - Pulled and sealed the well that was measured to be 4"Well 420'deep. Notified
and recorded with the MN Dept of Health
125.00 125.00
1 MDH State Notification&Records 5.00 125.00
35 Portland Neat Cement; 35 bags 260.00 1,040.00
4 Labor&Equipment for sealing well;4 hours 25.00 40.00
1 Trip&Fuel Surcharge Fees
Payment is due within 30 days of invoice. If payment in full cannot be made by the due
date please contact Brandi ASAP at 952-445-4809. Thank you
If we do not hear from you or receive a payment the balance due will be charged to the
credit card provided for hold.
*All !
$2,065.00
Terms: Net 30; If balance not paid within 30 days from the date of the invoice there Total _____.____ - -
will be a 1.5%finance charge applied monthly until paid in full Payments/Credits $0.00
We accept Checks for all work and Visa, Master Card or Balance Due $2,065.00 .f
Discover for service work only
Phone#
Fax# E-mail Web Site
(952)445-4809 (952)-445-1439 brandi@bohnwell.com www.bohnwell.com
AS-BUILT TIES
i PROJECT ADDRESS: l � \�-C ��h DATE: 3 22"- l b
NOTES:
fip
I
Show following items:
. Dimension to property lines
. Lengths of pipe,offsets in pipe,depth of pipe,size of pipe,type of pipe,offsets from house corners
. Show all termination points of draintile with ties to pipe(from two house corners)
. Septic tanks:length of pipe,height of risers,pump type and model,size of tanks,offsets to house/well/property lines/mound,float setting
. Sewer and water:length of pipe,depth of pipe,offsets in pipe,drop sections,offset between sewer and water,pvc and copper size and type
ties to curb box
. Drain tile:length of pipe,depth of pipe,slope of pipe,any interesections with other utilities,size of pipe,connections at house/garage/etc.
. Mount:size of rockbed/sandbed/downslope/unslope,lateral spacing,hole size and spacing,depth of sand,length of force main.
04 rRto Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
7.341/2vIVEscisr
Blue File
z.cola city PERMIT NO. ///.. /(7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/ (:-'/ —)l/7 ; ; . ,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) _ (Phone)
(Address)
APPLICANT: Phone: 952.758.2108
Benny's Plumbing LLC
211 2ns Avenue SE
New Prague
Contact: Ben Stienessen Phone: 952.292.8101
APPLICANT SIGNATURE 'A) V(, "fV DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
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
The Minnesota Statutes§326B.148 Residential,Additions&Alterations $49.50
"SURCHARGE"has been extended st $ Building Permit#
The minimum surcharge for a
"fixed fee"permit is$5M0 PLUMBING PERMIT FEE $
' STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Buildine Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
0-6 '
PR -(4
p
V.Aj
�j 1/70114:i/ Date Rec'd
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LifiNNESO A � ,�
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\J-i P N /p
I. Green ile PERMIT NO. /
2. Yellow City i p
3. Gold Applicant
(Please ty.e or .Tint and sign a bottom)
ADDRESS 17201 Sunset Ave SW ZONING(office use)
25-489-004-0
Kerni & Bradley Gustafson
LEGAL DESC:
LOT BLOCK ADDITION PID
OWNER
(Name) (t,r t 4 K€✓v; G i)k•' 63" (Phone)
(Address) i1Q.O V & litIVe. )/Nt.,CA3feA- Vlrtii,"
(Address) (City) (Zip Code)
APPLICV(Name) V\, l �/�.� ) `I50.•' TJi { ' �j3q0
�r�'',0,�jC -� `J ,(� �((P+hone ^�
(Address) Po 5c c q r6 Pr 1 l LC'. �J—_ v ) 5 S3 I D
(Address) (City) (DID -
,, (Zip Code)
16
(Contact Person) ^ � �
. � )tom^ (Phone) (Dl a ^ l p") UQ�— 3 )
APPLICANT SIGNATU'' i, 0 % -' E 5-30 - IL(
APPLICANT PLEASE COMPLETE BELOW
Size of water service 1 inches.
Location of any couplings from structur feet.
?
Type of sewer pipe. ABC PVC Cast Iron
Estimated length of sewer line LAC) feet.
Clean out(if required) located at feet from structure.
SLVVEK to WAI ER I'bKMI I I-be 01-
FEE SCHEDULE �L$56.50 PAID BY HOMEOWNER.
Residential sewer and water line connection $51.50 Industrial,Com'!&Multi-fl Sewer&Water Contractor MUST sign
Sewer connection only $25.50 Water connection only Sewer&Water Permit Form
Estimated Cost $ Building Permit
SEWER AND WATER PERMIT FEE
STATE SURCHARGE Permit Fee $51.50
TOTAL PERMIT FEE
State Surcharge 5.o0
TOTAL $56.50
(Office Use Only) `
This Application Becomes Your Building Permit When Approved Paid PAID det No.
BUILDING PERMIT
Date By
Building Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
(0,"1.,PR.)-04.
CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
{ cAll TEMPORARY CERTIFICATE OF ZONING COMPLIANCE y=_ /c , /4-
f....'` +! x AND UTILITY CONNECTION PERMIT
t P i. white File PERMIT NO. 4_ Z U /
N .---- 2. Pink City
3 Yellow Applicant
.eor grin* " ~
ADDRESS
17201Sunset Ave SW ZONING(oft-ice use)
25-489-004-0
Kerri & Bradley Gustafson
LEGAL DESC ,,,
LOT BLOCK ADDITION _ PID
OWNER .-7A / 69/f
(Name) /j.-�z.�"/' ( /c. (Phone) Y5 a-
(Address)
BUILDER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address) •
TYPE OF WORK ❑New Construction ODeck ❑Porch ORe-Roofing ❑Re-Siding OLower Level Finish ❑Fireplace
DAddition ❑Alteration ['Utility Connection
CODE: ❑I.R.C. ❑I.B.C. 0 Misc.
Type of Construction: I II III IV V A B PROJECT COST/VALUE $
Occupancy Group: A B E F HI MR SU (excluding land)
Division: 1 2 3 4 5
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the
above-mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building
official can revoke this permit for just cause. Furthermore,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
. - —E / Signature
Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $ Z 43 . U 0
Plan Check Fee $ Water Meter Size�/8'); 1"; $ !�'6 o U O
State Surcharge $ Pressure Reducer �t✓✓ $ // 0 . 6 b
Penalty $ Sewer/Water Connection Fee # $ /5-0 U 0 0
Plumbing Permit Fee $ 5-4 37) Water Tower Fee # $ / 00a , 00
Mechanical Permit Fee $ Builder's Deposit $
Sewer&Water Permit Fee $ S7. Other $
Gas Fireplace Permit Fee $ TOTAL DUE $S6'3 Co. Q 0
This Application Becomes Your Building Permit When Approved Paid .36' • G v Re ipt No. ICJ 9'94—
Date ,/v-I'¢ .
Building Official Date
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
when signed by the City Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy,a Certificate of Occupancy must be
issued.
Planning Director Date Special Conditions,if any
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
•
4646 Dakota Street Prior Lake,MN 55372
4 13111(4
A ;' `''e
(.) ' I ttr
4,iN N Esau`"
March 14, 2014
Bradley&Kerni Gustafson
17201 Sunset Avenue
Shakopee,Minnesota 55379
Re: SUNSET AVENUE UTILITY IMPROVEMENTS
SUBSTANTIAL COMPLETION(Project# 13-011)
The Sunset Avenue Utility Improvements are now substantially complete. A number of
cleanup items will be completed in the upcoming months and the final layer of asphalt
will be completed this summer. The utilities have all been tested and approved. You
may now hook up your home to the new sewer and water service stubs.
In order to make the connection from the utility stubs to the home, a building permit must
be obtained from the Building Department. A"Master Plumber", licensed in the state of
Minnesota must sign the plumbing permit. Also, a"Master Plumber"or a sewer and
water contractor licensed in the State of Minnesota for pipe laying must sign the sewer
and water permit. Building permit and connection fees of$5,786 or$5,636* are due at
the time of the building permit issuance. The fee amounts are 2013 rates and will apply
for all building permit and connection fees obtained within the calendar year 2014. Fees
for permits obtained after December 31, 2014 will be calculated based on the City's
adopted fee schedule. The connection fees for permits obtained in 2014 are calculated as
follows:
1"Meter
Plumbing Permit $54.50
Sewer and Water Permit $56.50
Sewer Access Charge $2,435
Water Meter(1") $740
Sewer/Water Connection $1,500
Water Tower Fee $1,000
$5,786
5/8"Meter
Plumbing Permit $54.50
Sewer and Water Permit $56.50
Sewer Access Charge $2,435
Water Meter(5/8") $590
Sewer/Water Connection $1,500
Water Tower Fee $1,000
$5,636*
J:\UTILITY CONNECTIONS\Sunset Avenue Utility Connection Letter(3).doc
Page 1 of 2
The building permit will stipulate requirements for the connection as well as
abandonment requirements for the existing septic system. Your existing well can be
maintained for outside non-domestic use or can be abandoned and sealed. It should be
noted that the sanitary sewer service is required to be located at least 20 feet away from
any well or the well will need to be abandoned. The building permit will give further
details regarding these items.
Sections 704.300 and 705.400 of the Prior Lake City Code requires connection to City
water and sewer within one year of availability. Section 4715.0310 of the State of
Minnesota Plumbing Code also requires connection to municipal sewer and water
systems once they are available. This letter serves as the beginning date for the one year
time period.
Attached for your convenience are copies of the building,plumbing, and sewer and water
permits. If you have any questions or concerns regarding the building permit process,
please contact the Building Department at 952-447-9850.
Sincerely,
Larry Poppler
City Engineer/Inspections Director
CITY OF PRIOR LAKE
CC: Robert D. Hutchins, Building Official
Page 2 of 2
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
PROCESS FOR NEW SEWER & WATER HOOK-UP (Building Department) 10/21/13
sz
1. Have Homeowner sign the Building Permit Application
2. Before any payment, Homeowner needs to know if they will have a 5/8"
Water Meter or a 1" Water Meter (the prices are different---5/8" = $480.00
+ $110.00 for water reducer= total of $590.00 or 1" Meter = $590.00 +
$150.00 = $740.00). Building Permit #, Sewer & Water Permit # & Plumbing
Permit # will all have same PERMIT NUMBER. Assign the # in next sequence
in Building Permit Roster.
3. For 2013* Fees are:
a. SAC Charge $2435.00
b. Sewer & Water Connect Fee $1500.00
c. Water Tower Fee $1000.00
i. Total $4935.00
d. Sewer/Water Permit Fee $ 56.50
e. Plumbing Permit Fee $ 54.50
i. Total $5046.00 $5046.00
f. Water Meter & Reducer
$ 590.00
Total $ 5636.00
$ 740.00
Total $5786.00
4. Complete a receipt for monies paid by Homeowner & give a copy to
Homeowner.
5. Make sure Homeowner understands that the Sewer & Water Contractor &
the Plumbing Contractor MUST sign the respective form even though the
Homeowner is paying the fee. PERMIT # CANNOT BE ASSIGNED UNTIL
HOMEOWNER AND BOTH CONTRACTORS HAVE SIGNED THE RESPECTIVE
FORMS.
*2014 Fees will increase by $50.00 for the SAC Charge. Other potential fee
increases are not yet known.