Loading...
HomeMy WebLinkAboutUtility Connection ui 9 ) § jliww $ z \ & � � \ \ z > 7 & aaaG 0 0 41 ti ' � 0 ) � � § § 5 � L0 § Z \ 000000 > g o 0 \ § aI / aa -3 m ® Z k w z 22 / z o F NE Ed oo . _ o 0 0 o 1- ■ o 00D < R - § - _ I k § 2 % § W2 ( a- 0 k ( 11111 2o � § no ... oo z w o ( } � 7 � ) � o oCe z \ OO . ■ aO . X )0 W M ® a a W 1 (....) k \ < 0 w \w N wz o 0 ) 'S 0 2 § 0 LU I- p < a / rez oi- ol \ 2 ° ° ° w � � to Z - , re ] aj W W ® u_ 3 w re w § § ■ . § w 2 0 § 025 25 0 2 0 E ° E2 ƒ 2 0 SSS \ O < 0 1000000 0 ° 0 E. SCOTT COUNTY, MINNESOTA Permit# 39334 INDIVIDUAL SEWAGE TREATMENT SYSTEM (ISTS) PUMPING PERMIT Owner 4_ f ,{ i /- Address } Pumper . ` No. of Tanks Pumped Total Gallons Pumped Check all that apply: I I Residential n Commercial ❑Rental n Septic ❑ Holding ❑ Pump Chamber n Cesspool n Abandoned ❑ Other: Condition of Baffles (baffles must be inspected) '.Acceptable n Unacceptable n Replaced Baffles Depth of sludge layer ' 5 inches Disposal Location (be specific) /7 ; `LL Did you observe a surface discharge? ❑ Yes n No Pumped From: , Maintenance Hole n Removed Tank Lid (stave, for example) n 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 Lid to enable the removal of solids. Signature of Owner/Owner's Agent Reason for not pumping through the Maintenance Hole,(Tank Lid Comments - O C t/< U ,'`' 7) t r r ,, ),_` `ti;' ,-1 c*-. ..,�...__.. r' Pumper/Inspector Signature 11,:r 'i :/ Date i 1 Only one permit is needed per ISTS.If there is more tl4an 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. White-County Canary-Homeowner Pink-Pumper Form#1120 • (oce,PR/04, CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd ,n TEMPORARY CERTIFICATE OF ZONING COMPLIANCE ft ! A< AND UTILITY CONNECTION PERMIT *NN65alr I. White File2. PERMIT NO.YellowPCity / /�� 3 3 ink `Applicant (Please j.a or .Lint and sign at tinttnml ADDRESS 1771 Shoreline Blvd ZONING(office use) 25-487-008-0 Stephanie &Anthony Risberg LEGAL DESCRIP LOT BLOCK ADDITION _ PID OWNER C. ' • p :)i �rp✓\a-vi('e1 Sb,(,V (Phone) qF)2 - -a5(p SO LI (Address) BUILDER (Company Name) (Phone) (Contact Name) (Phone) (Address) TYPE OF WORK ❑New Construction ['Deck []Porch ❑Re-Roofing ORe-Siding OLower Level Finish ❑Fireplace DAddition DAlteration ❑Utility Connection y�,�() 11 f CODE: DI.R.C. DI.B.C. I9 Misc. v 77 64 14/(f/lf� Q/�� Type of Construction: I II III IV V A B PROJECT COST/VALUE $ Occupancy Group: ABE F HI MR SU Division: 1 2 3 4 5 (excluding land) 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 offi' can r oke this permit for just cause. Fu••.more,I hereby agree that the city official or a designee may enter upon the property to perform needed inspections. Sig i re Contractor's License No. Date Permit Valuation Park Support Fee # $ , Permit Fee $ SAC # $oP1/0 0 0 Plan Check Fee $ 44. Water Meter Si(5/8"• $ 5-00_00 State Surcharge $ Pressure Reducer $ Penalty $ /5?) ' U� Sewer/Water Connection Fee # $ /50.0 0 Plumbing Permit Fee $ 3—'0.,S Water Tower Fee # $ /D0D, 00 $ Mechanical Permit Fee �---. Builder's Deposit $ Sewer&Water Permit Fee $ sZ. Q Other $ Gas Fireplace Permit Fee $ TOTAL DUE $ c5- 738 00 This Application Becomes Your Building Permit When Approved Paid Re -t No. `'�6 2- Date 8' i /J ( B// l// 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 • Brad Overby ••• vo, VAV Engineered Wood Market Manager _ * • „eh 2871 W.Service Road W ift St Paul,MN.55121 1111, ak (612)803-1580 Bluel..inx ler (651)452-5291 Fax brad overby@bluelinxco.com ..—, , I 7 I 4......................„...........„ 1 ...„ ., 4 1 r I ,Jr ( C i....' •••• •••. t P I. V I 0 Os 1 . ‘ ..1"-----------Z-..... 1 6 3 NAME: DATE: BY: COMPANY: ENOINIIREb PHONE NO: LOCATION: FAX NO: Alt;&,Georgia-Pacific n 01 13 IN 0E U November 8, 2013 Stephanie&Anthony Risberg 1771 Shoreline Boulevard Shakopee, Minnesota 55379 Re: CSAH 12 UTILITY IMPROVEMENTS (PID 25-487-008-0) SUBSTANTIAL COMPLETION The CSAH 12 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 next 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 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 $2,435 (Fee to increase to$2485 in 2014) 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 (Fee to increase to$2485 in 2014) Water Meter(1") $590 Sewer/Water Connection $1,500 Water Tower Fee $1,000 $5,636 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: Bob Hutchins, Building Official .„ # - , pwo 0 ,,,.1 6,,,, . ..„,„, „... ,,,,,, ,...,. ,, ,„„ . ,,„, \,,,,,-, 4646 Dakota Street SE `. / Prior Lake,MN 55372 41NNEsolt January 8, 2015 Stephanie Risberg 1771 Shoreline Blvd Shakopee, MN 55379 RE: IMPORTANT ANNOUNCEMENT CONCERNING CONNECTION TO CITY SEWER AND WATER Dear Property Owner: Prior Lake Ordinance requires that properties with dwelling units connect to city utilities (domestic water and sewer) no more than one year after the services become available. The one year deadline for your property was November 9, 2014. Five properties on the CSAH 12 project have not completed connection, although some are currently in process. Some have asked the City Council for extensions to the deadline. The City Council discussed these extension requests and all other non-connected properties at their regular meeting on November 24, 2014. The City Council has provided one last opportunity for property owners to connect by following the steps below: 1. By February 23, 2015,the Property Owner will need to secure a utility installation permit from the city, including payment of permit and connection fees. The cost for the permit is$5,686 for a 5/8"water meter. 2. Once the utility permit has been secured, the Property Owner will have 180 days(6 months) from the permit date to complete the physical connections through a private contractor. If needed,the City has a listing of companies who complete this type of work. Costs for connection will be based upon the immediate circumstances of each lot through quotes secured by the Property Owner. Some property owners have discussed demolition of the structure on the property. If a Property Owner intends to demolish the existing structure on the lot,then a demolition permit must be obtained from the city and the work concluded by February 23, 2015. As long as there is no dwelling unit on the property by that date,there is no need to connect to sewer and water. However,the fact that a property is for sale,occupied or unoccupied,will not affect the deadlines or process described herein. In accordance with City Code and City Council direction, if a Property Owner fails to secure a connection permit by the deadline shown above, or if permit is secured but the work is not completed within 180 days of the permit date,the city will be forced to take action to complete the connection. �q Phone 952.447.9800 / Fax 952.447.4245/www.cit}ofpriorlake.com __ 0 The City will seek a court order from Scott County District Court to inspect each property and authorize the completion of the connections. If this process is required,the City will secure quotes, award a contract,assure the work is completed,and impose a special assessment for all the costs associated with the connection including an additional administrative fee for the coordination efforts toward making the connection. We appreciate that connection is both a costly and time consuming process, but for public safety and health reasons, prompt connection to the city facilities is critical. If you have additional questions concerning this matter, please call me at(952)447-9832. Sincerely, Larry Poppler, P.E. City Engineer/Inspections Director CITY OF PRIOR LAKE cc: Frank Boyles,City Manager 0 r _ rrr 4646 Dakota Street SE �, ,%` Prior Lake,MN 55372 January 8, 2015 A,-*- —VD: (-73S NAME it-7 1 Address [ —1 1 i t/Le. 1 78f 08-6 06 leikr t / i 5meter RE: IMPORTANT ANNOUNCEMENT CONCERNING CONNECTION TO CITY SEWER AND WATERTt) 616 MOL/ Dear Property Owner: Prior Lake Ordinance requires that properties with dwelling units connect to city utilities (domestic water and sewer) no more than one year after the services become available. The one year deadline for your property was November 9, 2014. Five properties on the CSAH 12 project have not,completed connection, although some are currently in process. Some have asked the City Council for extensions to the deadline. The City Council discussed these extension requests and all other non-connected properties at their regular meeting on November 24, 2014. The City Council has provided one last opportunity for property owners to connect by following the steps below: ' 1. By February 23, 2015, the Property Owner will need to secure a utility installation permit_from the city, including payment of permit and connection fees. The cost for the permit is$5,686 for a 5/8" water meter. 2. Once the utility permit has been secured, the Property Owner will have 180 days (6 months);: from the permit date to complete the physical connections through a private contractor. If needed,the City has a listing of companies who complete this type of work. Costs for connection will be based upon the immediate circumstances of each lot through quotes.secured by the Property Owner. Some property owners have discussed demolition of the structure on the property. If a Property Owner intends to demolish the existing structure on the lot,then a demolition permit must be obtained from the city and the work concluded by February 23, 2015. As long as there is no dwelling unit on the property by that date,there is no need to connect to sewer and water. However, the fact that a property is for sale, occupied or unoccupied, willnot affect the deadlines or process described herein. In accordance with City Code and City Council direction, if a Property Owner fails to secure a connection permit by the deadline shown above, or if permit is secured but the work is not completed within 180 days of the permit date,the city will be forced to take action to complete the connection. Phone 952.447.9800 / Fax 952.447.4245/www.cityofpriorlake.com The City will seek a court order from Scott County District Court to inspect each property and authorize the completion of the connections. If this process is required, the City will secure quotes, award a contract,assure the work is completed,and impose a special assessment for all the costs associated with the connection including an additional administrative fee for the coordination efforts toward making the connection. We appreciate that connection is both a costly and time consuming process, but for public safety and health reasons, prompt connection to the city facilities is critical. If you have additional questions concerning this matter, please call me at(952)447-9832. Sincerely, Larry Poppler, P.E. City Engineer/Inspections Director CITY OF PRIOR LAKE cc: Frank Boyles, City Manager •6 3 -O O c F:, c co c o w a L 00° a, o O c Y 0 L a c. O = 0, c o O O 3 X v m E Q wF 300 E v = ro Y Y 0 O as u c a a co c o v ° ° 0) " o m v o QJ 4' a o $ V O 7 a c a, a, s° A' '+' 3 v 0 3 LE O 3 a, o 0- c 'L1 0 ° m 0) w ° v > a v c c ° ° 2 o 0 v • 3 L ° c 0 L C ° N y Va OO ON d C — ° a 0 L uO O LT C 0 3 N 0 O. yl O 0 Y 3 c b0 4 E c 0 3 .- u Lc CI. a, 0 L c too = O • N - O a, u .- oaN O a+ v s o c o 5 s u °` -° ro tla0T N - i>Oa O v ✓U O " u0 ° G o O ac O 0° 0 0. 'w o c .4 m a a' a co E0 L c v L ✓ o ._ c = o v 2 E c w "' m 3 0 0 w o d 0 °c L.. $ 'c a 3 a, 0 TO L a, c m no41 mi. o c .c3s n . O a on u ca v a, o_ c s -° ` E c wcY3 co oa a ° a flu E N c E -o o 5 y ° to" c > c a, s Y a, E c a, 42, a L r N r+ > yr O oa 5 > o ro '_ 3n3 = � v v v v ca c ° Q « 0 0 a ° v '°" .sj 0 ° ° n. c d 0 00 0 y o °_' o '06- L Y N Laa 0 3 0 io 3 L` L O •E 4 +' 5 -o a, ao 0-8 3 • 'o N C OCo 0 E O 0o v ai IT 0 R c v c 0 v v c 'a w w L Q J C 0 O 0 t -c •3 m 0 O T CU la N G O Ca 9 C O u c O u v c v a' a`) ai c C c >• T ai L 0 a n N. . a • co & N r) n N N m 0X CU o Oma, O '6 C O O y^CO ,1" f6 o c'"a tq ^ co ca `a 'o a) 0 i. d' rn c c W �, 'c1' O N E G X U v1 v G1 Q] U '�d' O ONi Cz�b 600i P�O 4NrivEse- July 24, 2014 Stephanie&Anthony Risberg 1771 Shoreline Blvd Shakopee, Minnesota 55379 REMINDER: 1 YEAR DEADLINE FOR UTILITY HOOK UP APPROACHING Re: CSAH 12 UTILITY IMPROVEMENTS (PID 25-000-000-0) COMPLETION The CSAH 12 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 11/8/13 regarding the hookup requirements. This is a reminder letter, per City Code, that your utility connection needs to be completed by November 9, 2014. 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 � 1(1)filL Water Tower Fee $1,000 $5,836 4A-- 5/8" Meter 1�-✓ � P � Plumbing Permit $54.50 Sewer and Water Permit $56.50 Sewer Access Charge $2,485 (1) I Water Meter(1") $590 94 Sewer/Water Connection $1,500 Water Tower Fee $1,0001? Phone 952.447.9800 / Fax 952.447.42451 www.cityofpriorlake.com 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 reminder of the upcoming one year time period which ends on November 9, 2014.Your utility connection needs to be completed by November 9, 2014. 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, L rry Poppler City Engineer/Inspections Director CITY OF PRIOR LAKE CC: Bob Hutchins, Building Official (reminder letter 1 year deadline shoreline blvd:j) v 4.? 0� FR.. , t.,,,,, , t„ „ .. ,.....,.. November 8, 2013 Stephanie&Anthony Risberg 1771 Shoreline Boulevard Shakopee, Minnesota 55379 Re: CSAH 12 UTILITY IMPROVEMENTS (PID 25-487-008-0) SUBSTANTIAL COMPLETION The CSAH 12 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 next 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 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 $2,435 (Fee to increase to $2485 in 2014) 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 (Fee to increase to$2485 in 2014) Water Meter(1") $590 Sewer/Water Connection $1,500 Water Tower Fee $1,000 $5,636 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: Bob Hutchins, Building Official CERTIFIED MAIL all )akota Street SE .ake,MN 55372 SERVICE REQUESTED 7014 1820 0001 7038 7081 Stephanie & Anthony Risherg 1771 Shoreline Blvd Shakopee, Mn . 55379 U.S. Postal Servicer' CERTIFIED MAIL° RECEIPT • Domestic Mail Only CaFor delivery information,visit our website at www.usps.com®. i f a rn Postage $ Q / Certified Fee ✓� Return Receipt Fee Postmark D (Endorsement Required) _ Here a Restricted Delivery Fee D (Endorsement Required) ru rD Total Postage&Fees Se51.0041 iAsterc Street& pt. D or PO BoxNN 171 Livie im City,State,ZIP+4 -- . _ PS Form 3800,July 2014 See Reverse for Instructions • O� pRI0* Erb' trl41:1:11) 4 SOf*P October 16, 2014 Stephanie & Anthony Risberg 1771 Shoreline Blvd Shakopee, Mn . 55379 ACTION REQUIRED:1771 Shoreline Blvd Re: PROJECT# 12-002, CR12; SHORELINE BLVD. UTILITY HOOK UP At this time, we have no record of any fees paid or work progressing on your City utility hookup for sewer and water. Please contact this office within 7 days of receipt of this letter to communicate your intentions to complete your utility connection (952 447 9850). If we do not hear from you, it's possible the City may issue citations and/or you'll receive an on-site visit from a building inspector. 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. Your utility connection needs to be completed by November 9, 2014. Again, please contact this office within the next 7 days with your intentions. Sincerely, Larry Poppler City Engineer/Inspections Director CITY OF PRIOR LAKE CC: Bob Hutchins, Building Official Lynda Allen, Building/Inspections Assistant (Letter for intentions shoreline blvd;j/utility connections) Phone 952.447.9800 ! Fax 952.447.4245/www.cityofpriorlake.com KISMES Kimmes-Bauer(Well(Drilling,(Inc. Invoice _ 22100(Lillehei(Avenue Hastings,(Minnesota((55033 Date Invoice# BAR (651)(437-1973 5/23/2016 44603 WELL DRILLING, INC. t:.. %Villa,. Bill To •, Ship To Josh Riz li, • Sealing No. H33665I 1771 Shoreline Blvd 1771 Shoreline Blvd Shakopee,MN 55379 Shakopee,MN 55379 P.O. Number Terms Rep Ship Via F.O.B. Project Due Upon Receipt Al I 5/23/2016 Quantity Item Code Description Price Each Amount L4 Labor to Pull Pump with backhoe 585.00 585.00 I CG Yd.Neat Cement Grout 400.00 400.00 I L3 Labor to Pump Neat Cement Grout 600.00 600.00 I APR Well Abandonment Permit 65.00 65.00 1 SU Paperwork&Filing Fee 100.00 100.00 Thank you for your business! Total $1,750.00 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H3 WELL AND BORING SEALING RECORD Sealing No. 6 u Cou Namel.4..... Minnesota Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. d 1 (Leas.Cane a„m y� J hi...tilt TITO No, Ra o. Section No. F ction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed GPS LOCATION-decimal degrees(to four decimal places) Depth Before Sealing ft. Original Depth ft. Latitude Longitude ��fj �G A FER(S) STATIC WATER LEVEL Numerical Street Address o Fire Number and Cl of I or BoringTV 1 'Ingle Aquifer ❑Multiaquifer I fi'/ t Sh Vi61 j 141 B1 l 1i y o LL/BORING asured ❑Estimated Date Measured_ ,' 1 _JJ 1 o f 1 I �j G4 jf,/�(,f ater-Supply Well❑Monit.Well r Show exact location of well or boring Sketch map well or boring ��/I,//) in section grid with"X" location,showing property Env.Bore Hole 0 Other r it. ❑below ❑above land surface N lines,roads,an buildings. CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other _ T WELLHEAD COMPLETION W ; ; EI ,__ Outside: ❑�^W�ell House ❑Al Grade Inside: ❑Basement Offset ; '%Mile }artless Adapter/Unit ❑Buried ❑Well Pit - - - - 6 ❑Buried r S Well Pit If Mite I ❑Other ❑Other PROPE R'S NAfyfijYCl NY NAME i* CASING(S) .�/� �I11��11 Diatngter DeA/, /1 �Settiin oversize hole? Annular space initially grouted? Property owners mailing address if different than well location address indicated above (-!y in.from to L!I/,/(t. Vs ❑No El No ❑Unknown in.from to ft. ❑(Yes ❑No ❑Yes ❑No El Unknown in.from _ to ft. ❑Yes ❑No El Yes ❑No El Unknown WELL N •'5 NAME/gAgAZAME SCREEWOPEN HOLEiii��� �//1 ���111 "� � Well owners maili address if different thanaproperty owner's address indicated above Semen from[o fl. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill )bstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring. PUMP r Tyle I).4/4 / r iii.">t/i I 1 II) gIII /,i i emoved ❑Not Present 0 Other tl•r w il _, ,,,i1 r,[-METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: /' CLYNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal „YON in.from to R. 0 Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well?❑Yes ❑No TN# GROUTING MATERIALS) (One bag o cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Materi t from 0 to±3Y Yards---- gs from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yeso How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION rr 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. —13W-C11" LAjek NI Licensee Bus erase Registration No. 34;b1 5 edified Representative Signature` Certified Rep.No. Date }"d.DEPT OF HEALTH DOPYa_ 1 t ' A • Name of'el-on Seal•g Well or Boring HE-01434-14 IC#140-0423 5/13R 6. ° © ¢UiIiI N ! CD 10-e 0 r-+) m y O C ° ' d 0 0 Lin C C Co `C �`0 P P ,-ca' P FA 4 ,), , V1 ccD CA o a � 4 CD " '" r y "...„ o E. „,0 0 ., H fp �s (- CD p, co 1E1la y M 1 hal co H ; ° CD _ cl c) 1 Z fP8 P. R- Jn yO o �• C ❑ Eat 111 a' °- 0 ° o co co . r o Z aQ El °, l0 -34 °14 y iti i. 0P Cb a. cp EY') wol� . .., • w w rr! _ R. g' E. 0 ((\���'Pp k 1 p O -, CD p. a -o cr .0 n n vj y 0 CMF.'! ° cA ° -+ CD Q- O m c v Oa cn i CD CD O- 0 O r—] ` 5 4 'Ciy p _ 0 "d o fp n O .i, Q CD a � ° ❑ w s+ 6 GSE m tD U40 ❑ p0. 'b \ b � � x EL CD N O 5 43 pci N : �& m 4t o r -,, �s' O o \NJ CA) 0 W CO CH U D • 3 c N O