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Q �� n§ �o \ 1 , ��k® � � 7 111=> !gEF" 53 -n■ -I� I gK 0 P -Ir 0 Mary Lein Am) G (Gr, From: Mary Lein Sent: Wednesday,July 22, 2015 11:25 AM To: 'Brandon@kawitt.com' Cc: Paul Baumgartner Subject: 17131 Sunset Avenue Hi Brandon, We are contacting you on behalf of Lois Tisdell at 17131 Sunset Ave SW in Prior Lake. A while back, KA Witt connected her to city sewer and water. There are a few outstanding items that need attention. 1. Curb stop must be at grade 2. Tracer wire box cover is missing 3. Pump ticket needed. You may or may not have arranged this. 4. Seal Well. You may or may not have arranged this. Please let me know the status of these items. I appreciate your time on this matter. Feel free to call with any questions. Regards, Mary Mary Lein ?So Engineering/Community Development CITY OF PRIOR LAKE � � 4646 Dakota Street SE I Prior Lake I MN 155372 Direct (952)447-9800 I Fax:(952)447-4245 44h-$04 ` mlein@cityofpriorlake.com www.cityoforiorlake.com 1 C). P Rips Date Rec'd H {`, ,y CITY OF PRIOR LAKE /0 Z�, `" ' ! . _, ,,, SEWER AND WATER PERMIT �jNNESD�P 1. ZYellow YeCCiteity PERMIT NO. /4.-1I/9¢, . • 3. Gold Applicant (Please type or print and sign at bottom) ADDRESSZONING(office use) /7 / / S ,Sed" 4((,) G - ez). /11/1 -57s"" 7" LEGAL DESC'!'TION(office use only) LOT BLOCK ADDITION PID OWNE(Name) I5 " , // s-cie!/ 1'S.z--' - 2,7 7 7 � � /� (Phone) (Address) / / X37 $'7S�7L Ab -) S kcre /71A/5 (Address) f (City) (Zip Code) KA, /Sewer & Water Contractor MUST Sign this formAPPmICANT ft' U � dirt Gl e 752--7.7�-(Wej/ (Name) r �,,� l_ 1� (Pho�nel) (Address) l7 50 ��'14` q/- �'QST Al ( ) 'Ca lite_ 0 4 ddress (City) (� (Zip Code) (Contact Person) f�Zr? 6y'1 " * (Phone) gSz" 75 t- �1'ld r APPLICANT SIGNATURE* AYDATE IQ/�,2(//i APPLICANT PLEASE COMPLETE BELOW Size of water service /u inches. Location of any couplings from structure ,414 feet. Type of sewer pipe. I I ABC RI.PVC I I Cast Iron Estimated length of sewer line 75— feet. Clean out(if required) located at N4 feet from structure. FEE SCHEDULE Residential sewer and water line connection $51.50 Industrial,Com'l&Multi-family 1%of job cost with a$51.50 minimum Sewer connection only $25.50 Water connection only $25.50 Estimated Cost $ Building Permit# SEWER AND WATER PERMIT FEE $ 51 .50 The Minnesota Statutes§32613.148 STATE SURCHARGE $ 5 .00 "SURCHARGE"has been extended TOTAL PERMIT FEE $ 56 . 50 The minimum surcharge for a "fixed fee"permit is$5.00 (Office Use Only) Sewer & Water Permit Fee of $56.50 to be paid by property owns This Application Becomes Your Building Permit When Approved Paid Receipt No. U BE PAID BY PR3PERTY OWNER SeW & Water _ e -' I 1 - •g Building Official Date t i I S for -F'2e/e/ 24 hour notice for all inspections(952)447-9850,fax(952) 7-4 � 4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 • O� PRION U !n113 . 44NNEsolt" October 2, 2014 Name Address Prior Lake, Minnesota 55372 REMINDER: 1 YEAR DEADLINE FOR UTILITY HOOK UP IS MARCH 14, 2015 XXXX Sunset Avenue Re: PROJECT# 13-011; SUNSET AVENUE UTILITY IMPROVEMENT COMPLETION The Sunset Avenue Utility Improvements are complete and the utilities tested and approved. You may hook up your home to the sewer and water service stubs. You were sent an initial letter on March 14, 2014 regarding the hookup requirements. This is a reminder letter, per City Code, that your utility connection needs to be completed by March 14, 2015. In order to make the connection from the utility stubs to the home, a Building Permit must be obtained from the Building Department(which also includes a Plumbing Permit and a Sewer&Water Permit). 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$5,836*are due at the time of the building permit issuance. The connection fees are calculated as follows: 1" Meter Plumbing Permit $54.50 Sewer and Water Permit $56.50 Sewer Access Charge $2,485 Water Meter(1") $ 740 Sewer/Water Connection $1,500 . Water Tower Fee $1,000 $5,836*(possible increase in 2015) 5/8" Meter Plumbing Permit $54.50 Sewer and Water Permit $56.50 Sewer Access Charge $2,485 Water Meter(5/8") $ 590 Sewer/Water Connection $1,500 Water Tower Fee $1,000 $5,686*(possible increase in 2015) Phone 952.447.9800 / Fax 952.447.4245/www.cityofpriorlake.corn Page 2 The building permit will stipulate requirements for the connection as well as abandonment the existing septic system. Your existing well can be maintained for outside non-domestic abandoned and sealed. It should be noted that the sanitarysewer requirements for 20 feet away from any well or the well will need to be abandoned. use or can be service is required to will located at least details regarding these items. The building permit give further Sections 704.300 and 705.400 of the Prior Lake City Code requires connection to Ci within one year of availability. Section 4715.0310 of the State of Minnesota Plumbingty water and sewer connection to municipal sewer and water systems once they are available. This letter serves reminder of the upcoming one year time period which ends onconnection Code also requires needs to be com feted b March 14 2015. Attached for your convenience March 14, are copies2015. copies of the building, as the y plumbing, and sewer and water permits. If you have any questions or concerns regarding permit process, please contact the Building Department at 952 447 9850.Also, please contac building within 30 days (by October 30, 2014) to communicate your plan. t this office Sincerely, Larry Poppler City Engineer/Inspections Director CITY OF PRIOR LAKE CC: Bob Hutchins, Building Official Lynda Allen, Building/Inspections Assistant (reminder letter 1 year deadline sunset avenue j/utility connections) N % AS-BUILT TIES PROJECT ADDRESS: \� I 3 �2, DATE: +b NOTES: 4 w \Jtt43 • SA/ QJZ---t 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. /F oR PR� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd s: :, TEMPORARY CERTIFICATE OF ZONING COMPLIANCE lo. i (' ' i ' AND UTILITY CONNECTION PERMIT �- . I. ��NES��P 2. Pink city PERMIT NO./¢ i 3 Yellow Applicant / ! /� gel. (Please type or print and sign at bottom) ADDRESS � r 6''-,'"- 77� ZONING(office use) / -7/�/ Sun set At e,) flak �e) /174/1 p 4/1 LEGAL DESCRIPTION(office use only) G21,44. .c'f g-- LOT BLOCK ADDITION PID c95:--4-?9?-6 /0--0 • OWNER 4 0. r 5 in • / `id / (Phone) -- -- --� 77 (Name) (Address) /7/3 / Ott,/ s. 2(---./4-vie. l'1 Q..k o F i /V 3/ 6 71 BUILDER (Company Name) SGt_'il'GZ,.-- (Phone) (Contact Name) (Phone) (Address) TYPE OF WORK ❑New Construction ❑Deck ❑Porch ❑Re-Roofing ❑Re-Siding ❑Lower Level Finish ❑Fireplace ❑Addition ❑Alteration gUtility Connection j �,�,i CODE: DI.R.C. D.B.C. ( Mise. "L ' " '1 . Type of Construction: I ' II III IV V A BPROJECT COST/VALUE $ Occupancy Group: ABE —1 2 3 4 5 HI MR S U (excluding land) Division: u 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. X Signature Contractor's License No. Date Permit Valuation Park Support Fee # $ Permit Fee $ SAC # $ 2485 .00 Plan Check Fee $ Water Meter Size 5/8"; 1"; $590 ,00 P$ 740 .00 State Surcharge $ Pressure Reducer $ Penalty $ Sewer/Water Connection Fee # $ 1500 00 Plumbing Permit Fee $ 54 ,50 Water Tower Fee # $ 1000 i 00 Mechanical Permit Fee $ Builder's Deposit $ Sewer&Water Permit Fee $ Other $ 56 .50 Gas Fireplace Permit Fee $ TOTAL DUE$5686 5/8 METER 01$ 5836.00 fjW/1" This Application Becomes Your Building Permit When Approved Paid X36 . 0 0 Re ipt No. ! 2_SSV Date Lb, 2i, <¢"" B . 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 p0 Date Rec'd A,0" CITY OF PRIOR LAKE PLUMBING PERMIT 4fliv vEs°i1.Blue File 2.Gold City PERMIT NO./44 3.Yellow Applicant (Please type or print and sign at bottom) ADDRESS ZONING(office use) /7/3/ A(ft/7 Sef .S/-,a./t"C2 r-0e) /7i// -"—'- LEGAL DESCRIPTION(office use only) LOT BLOCK ADDITION PID e t OWNER /S/ 1 c ��� 96-02—' 4-.C— o`l-J 77 (Name) (Phone) (Address) _ Plumber must sign this form even though Property owner is paying at APPLICANT: Phone: 952.758.2108 Benny's Plumbing LLC 211 2ns Avenue SE New Prague Contact: Ben Stienessen Phone:952.292.8101 APPLICSIGNATURE * DATE /4/21/4R (Ist 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 Residential,Additions&Alterations $49.50 • Estimated Cost $ 49 .50 Building Permit# 1 Ile lvi it111esuL s al.d1ute ,'-JLUD.i`t0 "SURCHARGE"has been extended PLUMBING PERMIT FEE $ 49 .50 The minimum surcharge for a STATE SURCHARGE $ 5 .00 "fixed fee"permit is$5.00 TOTAL PERMIT FEE $ 54 .50 (Office Use Only) mi.-. TX: a c, ,... 0 )GD .1 AO This Application Becomes Your Building Permit When Approved F s above to eRece,(pt No Property Wier , - ,,,r : . his form Buildine Official Date .4 ii-� 2-// I • 24 hour notice for all inspections(952)447-9851, a • - 4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 4 rRro Rec'd a �� CITY OF PRIOR LAKE PLUMBING PERMIT /0 Date /, 14— v �INNE50�� I. Blue File PERMIT NO./. fi p4_- - 2.Gold City 3.Yellow Applicant (Please type or print and sign at bottom) ADDRESS6-- ZONING(office use) /7/3/ SAVQ2 shy �� �r�r/ -,e� 77 LEGAL DESCRIPATION(office use only) LOT BLOCK ADDITION PID A b OWNER /5 m . 77 Z/,� ` 6-02—44.6 0,f / 7 (Name) (Phone) (Address) HII' II II I • il _ - I 14 . 11 I !- 1 . 1- 9_ . 111 APPLICANT the f:a #. j (Name) / U�1 [.{/Y9u-e 1 tti (Phone) `--.2 - 75-e-z/0f- (Address) 1 C30 (02e71- fi`(- 1400 7/cez4n. _ 1- 6-71. (Address)� ��f (City) (Zip Code) (Contact Person) Frear iL U u t c (Phone) ?5"--Z- 7$-r--2.168- APPLICANT // cfAPPLICANT SIGNATURE * 41010r DATE /0/2--///'‹ 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 Residential,Additions&Alterations $49.50 Estimated Cost $ 49 .50 Building Permit# Mie sysiciuesuLa al:at.uLe y Ocull.l.'ro "SURCHARGE"has been extended PLUMBING PERMIT FEE $ 49 .50 The minimum surcharge for a STATE SURCHARGE $ 5 .00 ."fixed fee"permit is$5.00 TOTAL PERMIT FEE $ 54 .50 (Office Use Only) TL... nQ:..........,.i--t.. C�.......4 0 0')413 1 no This Application Becomes Your Building Permit When Approved FPS above to teR I�edl °by Property Ojer, • :,�.� ,- . /I his form Buildine Official Date ,ll ii • �.'"z,J/'/ /U 24 hour notice for all inspections(952)447-9851, . - , 4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 7 0 6 6 3 is WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. County Name Minnesota Unique Well No. C d Minnesota Statutes,Chapter 103! or W-series No. (Lemke yank,,not known) Township Name p 'Township No, Range No. Section No. iaction(sm.r Ig.) Date Sealed (]7 Date Well or Boring Constructed IV 'PtI'vA _`Z '� ` 12 V E'%W 4C / 1'I SrOOL� r GPS Latitude degrees—._... minutes seconds Depth Before Sealing `g S. _.__ ft. Original Depth Lig J ft. LOCATION: Longitude degrees__ minutes seconds AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location q Single Aquifer U Multiaquifer 7 / C•�a '�V' k C° `_t (� C k� WELL/BORING ®Measured ❑Estimated Date Measured__ J ` si-wkci n J li W Water-Supply Well n Monit.Well /111 Show exact location of well or boring Sketch p of well or boring ❑Wal Bore Hole C Other V ft. below ❑above land surface in section grid with°X," . location,showing property N Iv lines buffs. CASING TYPE(S) 1 I 0 T,__/ t,ra. ®Steel ❑Plastic ❑The [';Other . --i WELLHEAD COMPLETION W _ E T Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset . 'h Mile ®Pitless Adapter/Unit ❑Burled ❑Welt Pit • --- ❑Buried s ''a< ❑Well Pit ❑Other------ -- — I I Mile---1 �.}Q1i ❑Other PRO �OWNER'S NAME1COti PA Y NAME CASING(S) l\1‘On, ''.S 01,4 Diameter r Deptt'y(�j Tot Set in oversize hole? Annular space initially grouted? Property owners mailing address it different than well location address indicated above 1 In.from to 3 •U ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown M.from • to tt. ❑Yes ❑No ❑Yes ❑No ❑Unknown _. in.fromto ft. CIYes U No Li Yes 17.-1 No n Unknown WELL OWNER'S NAMEJCOMPANY NAME SCREEN/OPEN HOLE Q S Well owners mailing address If different than property owners address indicated above Screen from to M. Open Hole from3 Q 0 to U J R. OBSTRUCTiONS la Rods/Drop Pipe ❑Check Valve(s) ❑Debris al Fill ;.I No Obstruction • • • Type of Obstructions(Describe)I,_6_2 -v ' ,.L� f 44"44-4., GEOLOGICAL MATERIAL COLOR HARDNESSFORMATIOR FROM To Obstructions removed? m Yes ❑No Describe._C,a5'�y ‘,.. .1I FORMATION ft not known,Indicate estimated formation log front nearby well or boring. PUMType ' 1 fVt t,tl� CIcY �f S I V Removed ❑Not Present ❑Other CIC^y+ S,,J 6 C[a` Is 31 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � Sn+ Coot Gf�,., P\ J f r7'7 L '••'(is®Na Annular Space Exists ❑Annular Space Grouted with Tremle Pipe n Casing Perforation/Removal PA in.from to ft. (1 Perforated ❑Removed �, cock (7f)c, w\ Cl?o y1s • In.from to._-.,-.___ ft _,Perforated ❑Removed Type of Perforator A, 13 t7 5 ❑Other ----_.- — Cp ^ OG� '''''''n\ t a GROUTING MATERIAL(S) (One beg of cement=94 lbs.,one bag of bentonite.50 lbs.) In R 1. tR ,p n' r Qr 1't�� ��1�' � Grouting Material i_/Q.Q� _._l.Q t from ( 10 uJ ft. yards 34 bags N 11), ` ` j1• r1r l^ .�I�V-1"' n�ti from to ft. __ yards_-,._ bags `bc. V� ,,,IgU from...-____- to_,. _..._._ It_.— yards bags 62 �a2tZ 92v OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? U Yes $No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION �DI b ���h •F(`u� 1 This wet or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report 7 �('tC Is true to the best of my knawledge,3C ha '�t�(,Ny�Il '',�•ufr— p 7 6535 � * \r1.1\ LLP — 1(22 560'' 4rrn �Q 4244,— o• _9-� L /_ _ Licensee Business Name License or Registration No. .rm, .T44 �/ 0 .08 tom, Certified epresentative Signature Certifed Rep,No. Date MINN. O HEALTH COPY H 1.. \1Gr�►'�IShh 270663 ,,G...)1 --- - _ ame of Person Sealing Well or Boring HE-01434.10 ICN 140-0423 5/07R WELL OR BORING LOCATION WELL pp MINNESOTAR9�k�pDEPARTMENT BOFM�HEALTH Minnesota Well and BoringH 3 2 2 514 /c-- Sealing lIIfELL AND BORING SEALING RECORD Minnesota County Name ori W seriesNUnique Well No7 L/ �„ •yC�_ Minnesota Statutes,Chapter 1031 (Leave bank,i eiewm) J Township Name�'�U'Township No Range No Section No Frlaatior71rn.r'Jg) Date Sealed Date Well or Boring Constructed %.-' '' ' / / it 94- 8 -'Jv w'Vra 1/ - 9..,8 -)-vay- 7 — /, — ) -- CO ', GPS LOCATION-decimal degrees(to tour decimal places) ]�, ,�J ]� L �• { C/ Depth Before Sealing `/ 'kms\J� ft Original Depth `/ 8 !J ft Latitude q. k/0/ 6 Longitude),5`" ;983 AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location 6 Single Aquifer ❑Multiaquder q p �1 + y T/3 1 6 . WELL/BORING [�Measured ❑Estimated Date Measured//"." 9 YU go/- 17 F I -/ .0e..44,"..41-e --iG.. (, 4,,Water-Supply Well❑Mont Well y�/` Show exact location of well or boring Sketch map of well or boring Env Bore Hole OtherI ® ❑above land surface in�No grid with" " location,showing property ❑ ❑ -! (t' ft below,t �V 7 y IineS,roadsnd buildings CASING TYPE(S) O f� RP Steel ElPlastic ❑Tile El Other , 1 4 WELLHEAD COMPLETION W E- X ���{{{,,, Outside ❑Well House ❑At Grade Inside ❑Basement Offset '`Mie \ [gf Pitless Adapter/Unit E Buried ❑Well Pit -- --- � ❑ El Buried • fi, Well Pit 4 ❑Other I iM,ie ❑Other..___ PROERTY„OWNER'S NAME/CONAM CASING(S) • Diameter Depth Set In oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above it in from0 to ' tt ❑Yes '4''No ❑Yes ❑No ❑Unknown �� I`,l�Jy ,in from to ft ❑Yes ❑No ❑Yes ❑No ❑Unknown nEC 2014 Y" y in Irom to R ❑Yes ❑No EC ❑Yes ❑No ❑Unknown WEL1�WNER'S NAME/COMPANY NAME_ SCREEWOPEN HOLE f� a , RLCC Y 1J �' Screen from to ft Open Hole from 380 0 to st es' ft • Wet "fes mash s,anit 1 that`d erry owner's address indicated above - �L4'''yyyyyy�,,,,,,������ dt snit ee.., �.� OBSTRUCTIONS /�l C �tk177 7 M1?`-4,1, ( Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction --'�`� Type of Obstructions(Describe)/69- i-'e-`^' - ; a G ;` • ,614/4!' . GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �"V� L'JsJJJJt i� Yes ❑No Describe .i "/" ,� FORMATION i7 If not known,indicate estimated formation log from nearby well or boring PUMP .,, 0 Type .-cse-4.e.�i'►'rN.-4.44 �—�'� /� ,,J �/� ,t' v - I '} [�Removed ❑Not Present ❑Other • �" 't ry' /T 'eltd_A/ ruL_. .� r7C METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE JJ J 8o "(a a No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal q ,.{�� in from to ft El Perforated El Removed - r '.J f-irte X1 1 /2iL e. 3,7i ..1:4 1.,#V4 - 3 76 it, in from to ft ❑Perforated ❑Removed Type of Perforator 14-4..-C ‘i 74` ' VARIANCE a Was a variance granted from the MDH for this well? ❑Yes No INS y¢ -4:d-- y..GROUTING MATERIAL(S) (One bag of cement/94 lbs,one bag of bentonite=50 lbs I r Grouting Material Cs s' it om / to 6)3 yards 39 bags —4-e-4,62--et 'Zs✓-a-€-esv -1.444444-e.-- from to ft yards bags -,-'[!t1'Cac�:' p a _ i/L 74 ,..4-3 3 5-/ _ from to ft yards bags OTHER WELLS AND BORINGS • REMARKS,SOlU/yRCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes ;M1'No How many? .14 -/j/1.&..,/t '4f / (241-4141•12/Z, LICENSED OR REGISTERED CONTRACTOR CERTIFICATION � , �, ,��y This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725 The information contained in this report 'k"'' aC. -- 'a'rm. %t.,..64... is true to the best of my knowledge 4"2:0 ' I Si. 9 ' c7¢7 ��y _ Licensee Business Name C .-y,._,�_,06.4-41,514-v-!, ��',y��y.� Licens/r Registration No �a.4'Le cs - �wryyL, ,[rt I--� 3 0 l9 ° '!J✓if , i¢.ts-.4 '"_T __ ,- e rJ 7 i "l'1.44,17•-4- it, 6-o'` '444:4- �'/�077�'rn k44-4L 2-/5 ASG 3 E d / V- I- //_ $ y d pl4' 9- 77 06 ` g Certified epresentahve Signature Certified Rep No Date i-MINN DEPT OFFHHEALTH COPY( H 3 2 2 5 1 �j �C�it.>�'� u✓t. "n'r iznl�t.� ,,� �' 4 Name of Person Sealing Well or Boring HE-01434-14 IC#140-0423 5/13R 6 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTARGWELL ANDD BORING NNO.O. County Name AND BORING RECORD SC.. Minnesota Statutes,Chapter 1031 7 6 5 3 51 Township Name 1 Township No. Range No. Section No. F io, N tV f WELIJSORING DEPTH(completed) DATE WORK COMPLETED 5,,,� La lly 22 Latitude degrees minutes seconds DRILLING METHOD LOCATION: g -- ❑Cable Tool L Driven 0 Dug Longitude degrees minutes _ seconds ❑Auger di Rotary 7 Jetted House Number,Street Name,City,andZipCode of Well Location or Fire Number ❑ 'i 131 �h�t fh,4t clta „„ DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ell No Show exact location of well/boring in section grid with"X.” j A Sketch map of well/boring location. W G.'ec From ft.To ft, 1r Showing property lines, N roads,buildings,and direction. USE gm Domestic J Monitoring U Heating/Cooling -- -----�---- --;.- . r]Noncommunity PWS -J Environ.Bore Hole '-J Industry/Commercial NOUS( ❑Community PWS ❑Irrigation LI Remedial Elevator ❑Dewatering 1.1 w I I E T CASING MATERIAL Drive Shoe? Yes n No HOLE DIAM. 'hMns Steel--1- -4 1 Lt.... ®Threaded [Welded r-_,-_, Plastic 0 f 5 x CASING 67 S N We Diameter+ R Weight Specifications /-----1 Mee — Li 1 in.to ft. 1 1 lbs/ft. . _ in.td 7Q n. PROPERTY OWNER'S NAME/COMPANY1NAME in.to tt. IbsJfL - in.to ft. Wi N CAA TS&G in.to ft. ____—_IboJfL L1 In.to%ft.i No A/ E OPEN HOLE Property owner's mailing address it different than well location address Indicated above. SCREEN Make From i'71 ft. To LI RS"+ ft. • Type Diem. _ Slot/Gauze Length__,_ _ Set between__ ft.and It. FITTINGS STATIC WATER LEVEL 9`O��12 Measured from 0 1 L1 0 ft.®Below❑Above land surface Date measured `10'01 WELL OWNER'S NAME/COMPANY NAME �i Jai PUMPING LEVEL(below land surface) 61 a AUG 2n08 a �_ ft.after hrs.pumping g.p.m. Well/boring owner's mailing address if different tha property otr r indicat�bove. WELLHEAD COMPLETION IAA 14. I+ : �(, iD li Pitless/adapter manufacturer 1QNIiQ` Model 01 WELL MGT. +LOQ J Casing Protection _ [12 In.above grade %r5�, , ❑At-grade(Environmental Well and Boring ONLY) 1� GROUTING INFORMATION '4 9Z 9JZa2 Well grouted ®Yes _No Grout materials 'J Neat cement'Bentonite 0 Concrete r i Other_ From � To3 2 r/ T ft. t ❑Yds. •Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. El Yds. El Bags MATERIAL From ,NNNToo ft. ❑11 Yds. El Sags ((may ��� /r 0 IS. NEARES_T'NOWN SOURCE e1 F C.ONTAM o direction r`I r�Q type 1 S 4 Well disinfectedupon completion? ®YesCLI No COY ���d may ,S U D PUMP 03 x (� C�y /1 NI �0 O El Not installed Date InstalledIn0 ��y l� Manufacturer's name I r..r N,D1-c)r 9 Model Number (Z~ (00 HP Volts L1 0 �`�� Length of drop pipe 161 ft. Capacity 12.. g.p.m. C104 tock aY!' f. tle r- 3/G y 10 Type:6Submersible L_L.S.Turbine n Reciprocating 7 Jet .] . ,tABANDONED WELLS 4 p'A r c.k (.,r0,)( m 41 D [O5 Does property have any not In use and not sealed wall(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? _Yes *No TNit WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. Use a second sheet,11 needed, The informationsn nVIn t re ort Is true to the t rrry knowledgq `Q ' REMARKS,ELEVATION,SOURCE OF DATA,etc. 1 ( -` r ' !/ 7 .4144.14-1 4.4.re GC .4t ,.e •cam-�Lf -� _-Lr`'W1�nn 3 I C i-P i 1,2 . 4-15 a 9/ H- 2- 70 66 3 Licensee Business Name Lie.or Reg.No. 2/...9-- 7-36_0 ' Cerullo Representative Signature Certified Rep.No. Date MINN.DEPT.OF HEATLH COPY 7 6 5 3 51r r 4n Rrtftlii Name of Driller IC 140-0020 HE-01205-11 lRes3/02)