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CITY OF PRIOR LAKEr-'
DEMOLITION PERMIT i
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- File
- City
. Applicant
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P~rmit No.
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(J5.09//
DIRECTIONS
1. DATE 9_ y-(.)~
BUILDING INFORMA nON
SPACES NUMBERED 1 THRU 10 MUST BE FILLED IN
BEFORE PERMIT ISSUED
(Please print or type and sign at bottom).
7. SIZE OF STRUCTURE
2. SITE ADDRESS .
19cQ ({,D J If (.) " r AJ lJ
3. LEGAL DESCRIPTION
LOT BLOCK PID :2 ~
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ADDITION C,-edi '" "'" ~ I - '"'t'O LA..; '",s.\,. P I \ \.- -
.<
.$(:.:> tT('ou ""Jr
8. NO, OF STORIES
I
9. TYPtJ)VPNSTRUCTION
10. COMPLETION DATE
4. OWNER (Name) /' _ LJ
~~~h1ren~
(Address)
(Tel. No.)
(Address)
(Tel. No.)
6. CON'liflACTOR (~"le) \ I (Address) (Tel. No.)
\.lrJ.," L\S~~ G,Jc}.-Q0(f -c'1)}Lf
I hereb certify I have furnished information which is to the best of my knowledge true and correct. I also certify that I am the
ower 0 authorized agent for the above mentioned property and that all construction will conform to all existing state and local laws
an~ will oceed in accor.d ance with submilled plans. I am aware that the building official can revoke this permit for just cause.
Fu therm re, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections.
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- . . - Signature . Date .
......-.. .,.
'LI .._,
FOR ADMINISTRATIVE USE
METRO SAC UNIT DETERMINATION
MATERIAL FILED WITH APPLICATION
o Site Restoration Plan
o Utility Abandonment Plan
o Sewer Abandonment
USE OF BUILDING
SITE RESTORATION PLAN
o Water Abandonment
Accepted by
Rejected by
o Electrical Abandonment
o Other
Occupancy Group A
B
E
H
R
M
CREDITS
Park Ded. Credit ................................................ $
SAC Credit ......................................................... $
Sewer & Water Connec. Fee Credit .................. $
Water Tower Fee Credit .....................................$
tic ~~~~~~~.~~.~~.;;~..::::::::::::::::::::::::: { J -
TYPE OF CONSTRUCTION:
II
III
IV
V
Divis~n
2
3
4
By
:Jt
Issued by
. Date
This is to certify that the request in the above and accompanying documents is in accordance with the City Zoning Ordinance and
~oceed as requested.
~~.~ ~!I(/rrs:
City Planner Date ~
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~;o.ny U Ji~:
IN/J,,~M - WARRANTY DEED
Minnesota Unifotm Convevanclnl! Blaolcs (6/1/97)
I
Individual(s) to Corporation, Partnership
Ot Limited Liability Company
Doc. No. A 668648
OFACE OF THE COUNTY RECORDER
SCOTT COUNTY, MINNESOTA
Certified Filed and/or Recorded on
No delinquent taxes and ~ransfer entered; Certificate
of Real Estate Value ( ../ ) filed ( ) not required
Certificate of Real Estate Value No.
t:bll~ 1M
(Dole)
-~ O~,~
) . \ Cpumty ~uditor /
.f by ~.-v- V7- - /
~ DEED TAX D~~ D- '14
i'Date: My u, Wl4
-
08-18-2004at 11: 15 Receipt: 403932
Pat Boeckman, County Recorder
01
Fee: $ 30.00
Deputy
OR /,0') 0" I~C
/53rtf'!
(reserved for recording data)
FOR VALUABLE CONSIDERATION, Marie K Sap,?T,.n,. and Flizahp.th A Kahler-Sangrene fllc/a Flizaheth A
Kahler, hushand and wif,.
(marital .tatw) ,
Grantor, hereby conveys and warrams to Shalenpep. Mdp.walcantnn SiOllT rnm'JlllIlity
Grantee, a
real property in
federally rec'lgnized Indian tri"" under the laws of the United States of America
C;:~Qtt County, Minnesota, described as follows:
See Attached EXHffiIT A
/
- WELl.....::n. ...."""TE RECEIVED
- WELl. CERTIFICATE NOTAEQUlRED
together with all hereditamems and appurtenances belonging thereto. subject to the following exceptions:
See Attached F.XHmJT R
Qleck box if applicable:
U The Seller certifies that the seller does not know of any wells on the described real property.
~ A well disclosure certificate accompanies this document.
o I am familiar with the property described in this instrument and I certify that the status and number of wells
on the described real property have not changed since the last previously filed well disclosure certificate.
Deed Tn of$ MlI(i.l.HA 1lI1'M.. f1 yaicI
No. ~'.JIIl',
Date ~/ICb (1J4. . ad
AffiX~~
ST=F MINNESOTA } ...
COUNTY OF 1IEM!r.",J
~~ v.. S~re
fMA.~ / A .4!.t{jA/' "':~____
Elizabeth A. KahIcr.San~nc
This instrument was acknowledged before me on
lulv ;:f)
. - DOle
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,
RIlANIQI
by Marl<- J( c;:
Notary Public
Minnesota
My Commission EXpI,es J'l>1 3 I . 7005
TIllS lNSTaVM.INT W AI DIlAFI'ED ay (NAME AND ADDIUtSS)t
Shakopec Mdewakanton Sioux Community
2330 Sioux Trail N.W.
Prior Lake, MN 55372
Larkin Hoffman Daly & Lindgren Ltd.
1500 Wells Fargo Plaza
7900 Xerxes Avenue South
Minneapolis, MN 55431
(952) 835-3800
WAMlINO: UNAUTHONZm COPYWO Of THIS FORM PIIOHIIITID.
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CITY OF PRIOR LAKE
INSPECTION NOTICE
SCHEDULED
1~s- nM,
i
2.~b
ADDRESS 'l- ~
(<{6~
OWNER
CONTR.
PHONE NO.
PERMIT NO.
r- 'I
,J' 11-
~!17
o EX/GRAD/FILLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
fG~~I~ST
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
o FINAL
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
COMMENTS:
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o WORK SATISFACTORY, PROCEED
YCORRECT C ION AND PROCEED
o CORRE T W ALL FO REINSPECTION BEFORE COVERING
Owner/Contr:
C L J?-9850 FO~HE NEXT INSPECTION 24 HOURS IN ADVANCE..
CODE R~NTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSNOTl
Site Restoration l)roposal for Demolition
Applicant: <.C;~f\\S(
Address: -dJw Ic;D Sf' IV uI _
Check boxes below:
--ti~ FiJI Excavation to grade
.-.e-- Sod or seed all bare soi Is
'0- Erosion control (see handout). Maintain erosion control until turf is established.
o Cap sewer below grade. * Mark location. Licensed contractor required.
o Cap water below grade. * Mark location. Licensed contractor required.
,. 'w Call City of Prior Lake Public Works Department for water meter removal.
-e:- Cap gas line.* (By gas company)
"'- Disconnect electric at meter. (By electric company)
i:.... Pump and fill cesspool/septic tank. Certified contractor required.
(~Abandon welL Certified contractor required. Existing well
-6- Remove existing structure foundation and footings, materials, and debris. * *
o Provide dust control by following means:
]. \Vater mist from a water supply (i.e. neighbors, water tank)
2. Enclosure
3. Other
Comments: (provide surve.v or drc7}v site plan)
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* Capping of utilities must be inspected.
** Final inspection and approval of restored site required.
aPQProved fina~I0b: nspection.
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Signature
Deposit will be returned after
V-Yc)s
Date
J:\BUILDINGdLV~=-)OLTSJ)elllo Slte Restor.doc
Oct 03 05 07:59a
952-466-4'797
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MINNESOTA DEPARTMENT OF HEALTH
WELL AND BORING SEALING RECORD
,,,:;, ,.,"";,, SIatute$, ChapleT 1031
~~SO:o~.U and BorIng H 231274
MinrleSOta UnlquliI WllII No.
or W.&8Iios No.
t\___...........
WEU. OR BORING LOCAllON
- COunty Nemo
~
T\+~br:
L6.J-e..
.0aIe we. Of Boring ConsINcl8d
Town""lp No. Ronge No. _ No. -F.-. lam .19) '0010 5e81ec1
11'1 rl 1, 'J,.,J 2-' sv4 ~$J.. Q-, 7 .-()~
GPS
LOCATION:
Lal"ude
mlnul8S
LongiIude degf8O$ """""'"
Numenca' S1reet AddreaS .tl{"e Number and elly o. Well or Boring LOClIlion
"L~O -1~O .... c.}. {)(~b( \..b.~o...
Show exact :. ~ ,:. . 01 willi or boriPll . SIuold1 ""'" 01_1 or bo<tng
In "..ction grid _ "X" . - ,;. . ahOllIling property
N lines. rOG. and buildings.
.-t-. .+1.+ '~1--
. . . .
. . , .
. . . ,
w --rT't+ n:._ E1
'_Y.. ._-~-- - ~_.. o+-t--
: ~ i ~ >>"...
-t..- .-t- -1n "1"~ 1
...
s
~ ,- +
\
(
.
~
'l't~ll
~RTVOWNER'S~NYNAM .
~ j)-. ~,
p ~maillnga ass" ""'Ihon_-ftl~~~
LV'" M"'''' fl.\
,
t..?-:z.,o ~ou..1- -'(f~" tJw
.?(,'D'f ~4l \.At'\. .;C;~Z-
WELL OWNER'S NAMElCOMPANY NAME
\~Ot\
i
It ".." DeplIl $- LI'
STA'l1C WATEI' lEVa
It.
~a:::;Sl
Oeplh Before Sealing
ri:~ Aqo*r 0 "'''li8qUlIer
WEUJIIORlNG
Qr.W_,SolppIyWell D _.we_
DEIlY. eon. Hole 0 Olher
yll MoasuTed 0 E$1W1IaIed
11b It- ~_
o abow _ surface
CASING TYfIE(S)
"$.s.oel 0 PlastiC 0 Tole 0 OIlIer
WEU.HEAO ~. . ...ET1ON
0_ D Well Ho&... ..._: D _lit OIIsel
Jl. PiIless AdapIor/Utli'
o Well Pi!
o Iluned
CASlNG(S)
OIa""l1er
11-- in. ffom_{)
.
o WoIl Pit
D Buried
0epIII
10~ft.
Set in CMltslzv """', Annular ap-.lnilialy grouled'1
"Yes OHo 1- Yes OND o Unknown
o Yos DNo DYes DNa o Unknown
DYes ON<> ayos ONo o UnI<nown
in.lrom
\0 ft.
in. from
10 It.
Wo. OWf1C,'S moOingaltdrns if CUllunm1 '8lIn., .,"
_._....Indiaol""_
-----
SCREt ." <
Screen from
10 ft.
GEOLOGICAL MATERIAL I eOLOR IHARDNESS 01'1 ffIOM I TO
FOflMAllON
U _"'-n, _osl_1od .........ionloSl r..... """'*'v-"'-
._~
Open Hole from ~ to '?,~~
fl.
OasTRL ~...", '"
o RodslDrop Pipe 0 Chock Valve(s) a Debris 0 Fill )it. No Obstruction
Type of Obslructions (Describe)
Obstructions removEld'l a Yes
aNo
Dascribe_.
\")-(t \-\
<+,,~.-
u~"\oo~ ~
PUMP I
I Type .c:;.\l\.\ll'Y\t"'V~
() 2Jj ~Oved 0 No! PrG$8nt D Other
'~1 ~ 1_,: , . . USED TO SEAL AMlUUlR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE:
~ Annul;or Spoc:o EJOaIs D Annula, space groutod wilh tromie pIpo 0 QJsing Perloraliol>/RGlI'IO'IlIl
In. from 10 h. 0 Per10raled a Removed
REMARKS, SOURCE OF DATA, IlIFFlClILllES IN SEALING
;,'.C:X~ I;\dr-i~il.r: WITH pr-loPSrny
I....
?~1?74
tn, from
10
h.
o Perforated 0 Removed
Type of perfOlator
o Other
GIlOUTlNG _TEIIIAL(S) lon.1NIg of .
GrouIOlgMat_-*h-l- r~.\-- !rom
" 94 u.... ..... ''''9 01 bentDnI1.. " 50 Ibs.)
() 10 .2C;~ 11
yalds ~ bo.gs
horn
10_._11.
yard$
bag,
',om
10_._11.
ya.o.
bags
OTHEll wELLS AND 1I0_GS
au- unsealed and unuaod wetI or boring on , ... . ,.../1 0 Yes ~ How muny?
LICENSeD 01' REO"". .,:........ ~. .,' ACTOI' CERTlFlCATION
This"'" 0< boring...... _ In. ... .:,.. oe lOilh Minnosota _s. Chapl... 4725. Tho inlolma_ c:ontain8d in this ,oport is
"uololhebeslolmy~ . ".,...
\ rlb.2l_
. tiCemR 01' Regis/AIIion No.
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A~
9~'(\-I\\\ ~ - ~ UlVltJe....
Q.. ~ 17 -(}c:
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