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906 Lakewood Hills Rd SPERMIT City of Eagan Permit Type:Building Permit Number:EA128864 Date Issued:12/11/2014 Permit Category:ePermit Site Address: 906 Lakewood Hills Rd S Lot:20 Block: 0 Addition: Lakewood Hills PID:10-44350-00-200 Use: Description: Sub Type:Fireplace Work Type:Gas Insert Description: Census Code:434 - Zoning: Square Feet:0 Occupancy: Construction Type: Comments:Improvements to the home may require smoke detectors in all bedrooms. Chimney / flue must be inspected prior to concealing. Carbon monoxide detectors are required by law in ALL single family homes . Valuation: 3,000.00 Fee Summary:BL - Base Fee $3K $88.50 0801.4085 Surcharge - Based on Valuation $3K $1.50 9001.2195 $90.00 Total: I hereby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. Contractor:Owner:- Applicant - Keith H Olsen 906 Lakewood Hills Rd S Eagan MN 55123--191 Glowing Hearth and Home LLC 100 Eldorado Dr. Jordan MN 55352 (952) 492-9276 Applicant/Permitee: Signature Issued By: Signature ? PERMIT # PLUMBING PERMIT RECEIPT q d d CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: ?' '?? •P CONTRACT PRICE_ q?? / '/?(' ,,.,„j u,q/pBHONE: 454-8100 itite Address I?kf f. G Lot r? BIOCk ?ec/Sub I ? Name CIIP - (tp , ?a Address c Ciry =?>;E Phone ` - ? Name 3 Address p Ciry Phone FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE 8 CONDO - RES. RATE APPLIES MINIMUM - RESIOENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000.00) , .1 4" X y1% ' - ? _ ?// ? ! ? T 1 .?? SIGNATURE.Qf PERMITTEE CITY OF EAGAN BLDG. TYPE WORK DESCRIPTION Res. New Mult. Add-on Comm. Repair Other RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES TOTAL -Water Closet - $3.00 $ _Bath Tubs - $3.00 -Lavatory - $3.00 -Shower - $3.00 _Kitchen Sink - $3.00 -Urinal/Bidet - $3.00 _Laundry Tray - $3.00 _Floor Drains - $1.50 -Water Heater - $1.50 _Whirlpool - $3.00 -Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIT) Softener - $5.00 =Well - $10.00 _Private Disp. - $10.00 _Rough Openings - $1.50 ?, - FEE: STATE S/C: ? ; GRAND TOTAL• '/? PERMIT # • PLUMBING PERMIT RECEIPT It ' • . CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE >NTRAGT PRICE i 0HONE:454-8100 Site Address - ?? ?• Lot ??A Block Sec/Sub ? Name ,v-!.? 7ii Address y c City Phone Name 3 Address O City Phone FEES COMM/IND FEE - 196 OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE 8 CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES aEVOrvo $1,000.00) SIGNATUREO PERMITTEE BLDG. TYPE WORK DESCRIPTION ? Res. New Mult. Add-on ? Comm. Repair Other ; RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES TOTAI ? -Water Closet - $3.00 $ ( _Bath Tubs - $3.00 j r. _Lavatory - $3.00 Shower - $3.00 Ki!chen Sink - $3.00 -Urinal/Bidet - 33.00 _Laundry Tray - S3.00 _Floor Drains - $1,50 -Water Heater - $1.50 _Whirlpool - $3.00 _Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIT) SoRener - $5.00 -7-Well - $10.00 _Private Disp. - $10.00 _Rough Openings - $1.50 FEE: " STATE S/C: ? FOR: CITY OF EAGAN GRAND TOTAL: y , _? - -- _ _ __ ? ? -.____--------- -- - ----- - _' PERMIT# ' -=- • PLUMBING PERMIT RECEIPT # ' • CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAN, MN 55122 DATE: 'RAGT PRICE: PHONE: 454•8100 J' SiteAd?re?s ` Lot ock ?GlSub '. ? m Name (D AddreSs c City? ,fi •t c4-' Phone ,c. Name ?ok r.{c?•'- 3 Address O City Phone FEES COMM/IND FEE - 1% OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND $1,000.00) ? a ? _F . .. i i?i ...r! e ???) ?:.:'? SIGNATURE OF PERMITTEE ? CITY OF EAGAN BLDG. TYPF Res. ?- WORK DESC,RIPTION New X Mult. Add-on Comm. Repair Other RES. PLBG. ONLY - COMPLETE THE FOLLOWING: FIXTURES ?Water Closet - $3.00 TQTI,L $ ? Balh Tubs - $3.00 Lavatory - $3.00 ?- ?Shower-$3.00 Ki?chen Sink - $3.00 ? UrinaliBidet - $3.00 -rLaundry Tray - $3.00 =Floor Drains - $1.50 ??- 11 Water Heater - $1 50 Whirlpool - $100 = Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIT) _Softener - $5.00 -Well - $10.00 -Private Disp. - $10.00 ?- .Rough Openings - $1.50 FEE: ?-?STATE S/C: - ?? GRAND TOTAL• '1=i , -rr, ?' • • . kdaress ? ?, Name _ ? Address c City _ ? Name ? Addre O Ciry _ PLUMBING PERMIT CITY OF EAGAN 3830 PILOT KNOB ROAD, EAGAI Phone FEES COMM/IND FEE - 146 OF CONTRACT FEE APT. BLDGS - COMM RATE APPLIES TOWNHOUSE & CONDO - RES. RATE APPLIES MINIMUM - RESIDENTIAL FEE - $12.00 MINIMUM - COMM/IND FEE - $20.00 STATE SURCHARGE PER PERMIT - .50 (ADD $.50 S/C IF PERMIT PRICE GOES OF EAGAN BLDG. TYPE WORK DE $.CRIPTION Res. New ??? Mult. Add-on Comm. Repair h Ot er RES. PLBG. ONLY - COMPLETE THE FOLLOWING: NO. FIXTURES TOTAL -Water Closet - $3.00 S -Bath Tubs - $3.00 -Lavatory - $3.00 -Shower - $3.00 -Kitchen Sink - $3.00 -Urinal/Bidet - $3.00 -Laundry Tray - $3.00 _Floor Drains - $1.50 -Water Heater - $1.50 _Whirlpooi - $3.00 -Gas Piping Outlets - $1.50 (MINIMUM - 1 PER PERMIn -SoRener - $5.40 Well - $10.00 ? Private Disp. - $10.00 _Rough Openings - $1.50 FEE: STATE S/C: ? ??..?. GRAND TOTAL: Z 2 • t"V MECHANICAL PERMIT X ? RECEIPT # . CITY OF EAGAN 3830 PILO T KNOB ROAD, EAGAN, MN 55122 DATE: CONTRACT PRICE: PH NE: 454-8100 Site Address LotBlock ? ? $ec/Sub BLDG. TYPE WORK D rIPTION Res. x New ?. Mult. Add-on °-' Name Comm. Repair ?n c Address c/ in?- Ph City' Other ? one J FEES ' ? Name RES. HVAC 0-100 M BTU -$24.00 ? Address ADDITIONAL 50 M BTU - 6.00 , 3 p City ' Phone (RES. HVAC INCLUDES A/C ON NEW ? CONSTRUCTION) GAS OUT ETS MINIMUM 1 PER PE MIT ( L - R ) - 1.50 EA. TYPE OF WORK COMM/IND FEE - 1% OF CONTRACT FEE I Forced Air M BTU d APT. BLDGS. - COMM. RATE APPLIES . Boiler M 8TU TOWNHOUSE & CONDOS - RES. RATE APPLIES MINIMUM RESIDENTIAL FEE-ALLADD-QN& ? i UnitHeater '' - MBTU $ - REMODELS _ 12.00 ., Air Cond. M BTU MINIMUM COMMERCIAL FEE - 20.00 Vent. CFM $ STATE SURCHARGE PER PERMIT - 50 Gas Piping Outlets # ? U (ADD $.50 S/C IF PERMIT PRICE GOES BEYOND. $1,000) ! ? Other FEE: -G1i Z-P ' S/C: IGNATURE OF PERMITT E ! ! TOTAL: FOR: CITY OF EAGAN . .. . CITY OF EAGAN 3830 Pllot Knob Road, P.O. Box 21 •198, Eagan, MN 55121 ? PHON E: 454-8100 BUILDING?PERMIT Receipt ik To be used for ' Est. Value Date ,19 Site Address Lot Block ' Sec/Sub. Parcel No. a Name z Address ° City Phone 0 .` Address I P City Phone Address City _ I heraby acknowledge that I have read this application and state that the information is correct and agree to comply with all applicable State of Minnesota Statutes and City of Eagan Ordinances. SignaWre of Permittee _ A Building Permit is issued to: ' - on the express condition that all workshall be done in accordance with all applicable State of Minnesota Statutes and City of Eagan Ordinances. OFFIC E USE ONLY OnSiteSewage _ Occupancy - "? MWCC urystem Zoning On Site Well (Actual) Conat City Water _ (Allowable) PRV Required of Stories Booster Pump Length Depth S.F. Total I Footprint S.F. , APPROVALS FEES Engr./Assess. Permit Planner Surcharge Council Plan Review Bldg. Ofi. SAC, City Variance SAC, MWCC Water Conn. Water Meter Road Unit 7reatment P1 Parks TOTAL f)!? .,itt1 ? i I ? I .' Permit No. Permit Holder Date Telephona # Plumbing • ?1 ??.5 ?'?/? ?Y[iatcl?,. `??.5??1 b' ,?(y J Y (c- ??7?? Gcl4k?L Electric Softener Inspectlon Dats Insp. COmments Footings I Footings II Foundation Framing ? ?6l Roofing Rough Plbg. _ Rough Htg. ? e Isul. r Fireplace -z5?',?'?iO Final Htg. 1.,d Final Plbg. Bldg. Final Cert Occ. ?zg Temp. LP ? Deck Ftg. Deck Final Well Pr. Disp. _2 d7-? . CITY OF EAGAN N2 15 2 2 5 3830 Pilot Knob Road, P.O. Box 21•199, Eagan, MN 55121 ' PHONE:454-8100 ?2??C? BUILD,ING PERMIT Receipt ?? # Tobeusedfor SF DWG/GAR Est.Value $113,000 Date NNE 21 19 88 SiteAddress 906 LAKEWOOD HILLS RD (S) I OFFICEUSEONLY Lot 20 Block 00 Sec/Sub. LAKEWOOD HILLS On Site Sewage X Occupancy Parcel No, MWCC System _ On Site Well X Zoning (ACtual) Const (Allowable) # of Stories Length Depth S.F. Total Footprint S.F. R-3/M-1 R-1 V-N V-N 50' 50' x Name BROFIN BUILDERS City water = Address 10000 JUSTEN PRV Required 3 0 City MAHTOMEDI Phone 426-4370 Booster Pump - tiQlName SAME I o? Address ? City Phone U? W W Name _ ?W _z a Address U aW Clty- I hereby acknowledge that I have read this application and state that the information is Correct and agree to co ly with al pplicable State of Minnesota Statutes and =oga ilres Signature of Permittee _ x A Building Permit is issued to:_ BROWN BUILDERS on the express condition that all workshall be done in accordancewith all applicable State off ?Mi_n?n?e_sota Statutes and City of Eagan Ordinances. Building Olficial '?1KV?L_I_m,t' APPROVALS FEES 616 00 En9r./Assess. Permit . Planner Surcharge 56.50 Council Plan Review 308.00 81dg. Off. SAC, City ___ Variance SAC, MWCC - Water Conn. Water Meter Road Unit _32 ?500 Treatment Pt _ Parks TOTAL 1,305.50 This re0uest void C/??` 18 mpnthS from ??7 C 8640172i-s?v . b?(n `7SL5 Hequest Date ' Fre No. RouBh-in InspeCtion Required7 ' eady Now Q Will Notity, Inspec- ? r ? Il'"1?/_S ONo tor When Ready 4k'° icensed Electncal Contractor I hereby requestinspection of above ? Owner electrical work instalied et: Street Address, Box or Route No. `/ 4'(? ? ? ?.?tvD p p /?rGc- 5 e Cit? ecuon o. I I Township Name or No._ anee o. County ' C' 0 G rj 4? . OccUpant (PRINT) Phone No. Power Supplier ? Address ?-•r Ele cal Contractor ICompan?y Namel 14 ?V??/????? f---' VF-(..?? CQontral,ct?o!rs liconse No. !!TV TV T Y Mailin9 Addre 5 (Contractor or Owner MakinB Instailation)/? uthor' ed Signeture (Co actor/Owner a ng Installationl Phone Number ) r 7/'r3d ?-,7 MINNESOTA STqTE BOAND OF ELECTi11CITYTHIS INSPECTION HEQUEST WILL NOT Grigga-Midwey Bldg. - Noom N-191 BE ACCEPTED BY TNE STATE BOARD 1821 UniversitvAve.. 8t. Paul, MN 65104 UNLESS PNOPER INSPECTION fEE IS Phone(612)642-OS00 ENCLOSED. ?J(S /pf REQUEST FOR ELECTRICAL INSPECTION . Q I0, See inatructions for eompietirg this form on beck oi Yeltow copy. %Wcyr,P - '~• "X" Below Work Covered by Ihis Request (' "y??A (5 0 NOWN AAd ReO. Tvpe of BuilOinB ADDliances Wired EquiVment Wired Home Range Temporary Service Duplex Water Heater Lightin,y Fixtures Apt. Building Dryer Etectric Heatm Commercial Bldg. Fumace Silo Unloader Industrial Bldg. Air Conditioner Bulk Milk Tank Farm ther oeci v ther (5pecify) t Rr Sueci y t er Other Compute fnspection Fee Below N Fee Service Entrence5ize d Fee Faeders/Subfeeders # Fee Circuita ` 0 to200Am s 0 to30Am s C? Oto 30Am Above 200 qmp5 31 to 100 Ainps ? 31 to 100 Amps Swimmin Pool Above 100_Amps Above 100_Am ' Transformers Irri ation Boorc?s . SU Partial-'Other Fee Signs Special inspection SQ TOTA FE emarks - 1 ? RouBh-in Date !.? the Electrical Inspectoq hereby ce tily thet the a6ove Final ??j ? ( ??1e 44' spection hes been J/.1 ? _ _ /1?' t//^j' made. TMS request voltl 18 monlhs irom I , " . a 1988 BOILDING PERMIT APPLICATION - CITY OF EAGAN .. SINGLE FAMILY DWELLINGS INCLUDE 2 SETS OF PLANS, 3 CERTIFICATES OF SURVEY, 1 SET OF ENERGY CALCULATIONS NOTE: ADDRESSES FOR CORNER LOTS - CONTRACTOR/HOMEOWNER MUST DESIGNATE WHICH ADDRESS IS DESIRED. NO CHANGES WILL BE ALLOWED ONCE BUILDING PERMIT IS ISSUED. MULTIPLE DWELLINGS RENTAL [JNITS FOR SALE UNITS # OF UNITS INCLUDE 2 SETS OF PLANS, CERTIFICbTE OE SURVEY - CHECK WITH BLDG. DEPT.v 1 SET OF ENERGY CALCIILATIONS COMMERCIAL INCLUDE 2 SETS OF ARCHITECTURAL & STRUCTURAL PLANS; 1 5ET OF SPECIFICATIONS. AND 1 SET OF ENERGY CALCULATIONS To Be Used For: * c ¢Rm=/? Valua LjC.'(. 4-..cLw:cu P-I10I-1?:rr1D 6 Site Address -'.a 4-r, Lot 20 Block G r' L4, kE Woa( 9 "?/s .A> >17/a Parcel/Sub , er OpAddire &+ t)'1 i?1 r City/Zip Code ggAIJ S,i"l a 3 Phone Contractor Address /O.UpD City/Zip Code //l.a &lrtFd % Phone ?66- 4;/3 ')b Areh./Engr. r---- Address City/Zip Code `- . 1/3 000' Date: 6 - /? b'8 On site sewage -z Oecupaney R-3 M-I MWCC system Zoning R-I On site well :2- Actual Const V- N City water _ Allowable PRV required _ # of stories i Booster Pump _ Length d j Depth 50' S.F. Total Footprint S.F. FEES Engr/Assess Planner Couneil Bldg. Off. Varianee Permit (0I6, o0 Surcharge 561so Plan Review cR oa SAC, City /po, vo SAC, MWCC 0S0, po Water Conn s?0, oo Water Meter u (-,r7,0 Road Unit 3 ZS.i 00 Treatment Pl 1 04, o0 Parks Copies TOTAL Phone Il , ' VAL c-k AT?Ot4 P ? Za Izxt t-l- i?, s 2 yq = iB I I y o z r? (, Vzl16= I,? llZq2y Mr. Russ Grimmer 9O& ..,04K!;:A? nn rakeview-Heights-Road f Eagan, MN 55123 `5)' 124/21 (?/p DELMAR H. SCHWANZ UNO $UAVEYORS, INC. , Hop91NS0 UnAer Uwa ol The Stus o1 Minnseota 14750 SOUTH ROBERT TRAIL R03EMOUNT; MINNESOTA 55088 612/423-1759 _... • . •- oo% ..?i:?f Scale: 1 inch = 100 feet 2 /=oUNO Ilce/ 3 ?' I SnufJ! oFCo,e,yW ? FE7VfE PoSr -? 360- o ? SURVEYOR'S CEATIFICATE ? ? '/4S s SCTI/lan/ o fOUiJO ]ROI! . . a R/W As D2dicated-On Piat Y ' S? 16 -7»n/- 2234v • Survey of the common lot line of Lot 19 and 20, LAKEWOOD HILLS, according to the recorded plat thereof, Dakota County, Minnesota. 1 hereby certify that thfa auney, plsn, or report wse prepered by me or under my direct auperviaion entl"' •' ° • - that 1 am a duly Regiatered Land Suneyor under the Iaws of the State of Minneaote. Field Work 12-17-87 Deimar H. Sehwenz Dated ? Minneaote Reglstretlon No. 8825 Certificate Drawn 01-14-88 •'. : ? • ` • • . UE1KT ::?S t?r?t'? EIa?Jt'711 Ca?tr?ctar ??4'Jz L BlLC1Wt•j ? _ . Ct1tYt?L'o?f 7QAf ?? .?? "?CM :JC• ? ?de' ?' ',ot of 7v?t?in? SGr'? t ?.Ni°lfv? ??? • ,ti V I j ?SSC"=? "?:•01? :y1C7;8!:Of!1 '7? ?OrlS?fttS ::?!' '1'rdt;,if i I? f .? . ? '„s;;Iated alH: Arm, Ser 1) ! ?3LZ ? Q?I Cj ? Z?j.??• . ? f ..a,.?.r e.14:•:tT: ]f '7U) re;!; irN. SN •'; . ZT j 3 ?_• 4. >>> Grf, to A Rz tu5U:., ; L4?" j '? ; 4,a.b3 I 2; Vtf3LT-0 " U FP^ I ?3 i l0 ?p b ' z, ? Z,3ts ? ?? qV I 2! A.r.n;e U-value, 'i.Al:'Ai Lmt I ? -?^ ? •DZ'F ; --. ' ..? .a • 3' R. ??.__ `!-Ja:.,e fcr :,e ana :w .sa,t, _.el., -;s :niy) ?? ••.?• ]i ' atlf .YJfI Arll. :KS Nin.Ow Lnd 57 ; t1L: X+; ?•54'3.e. -,.? ?Oar z,.i, sn =:5. 31 17. . . ? tl? en i ` ?07 n ,$,, i ?J ,.,_?s =•?, ??? " ! ? 14 I T' ? ' t?l, `?5`; i DoorS .c-pm ?.,H" 1} 7,dO :,j,5t -.,,: see Zo1 : ?04',,q° ' ?,743 ? j 3 'F ,. ;,c. ',u,,l: ? "'? , 3=?ar?ar? .vaf!? i?oYr ?.ade? ?ess N'nc'-+. , ' ? . taor ?i ?? linf 7 • i? 'M49s !ian L,n* 17, Ata osrpcts &f rtCUam: ;o L:^! 7 !o#s •,ot ar:ee4 l;nt 10. 1 if L:wf 1 i! iti{ :1?f1 ?in? ?Q. SH?9t10 •fiN1Q1?IH ?f![ :-?f •ea??*r-?nts. E 1 . CChtr: ?escrSd i i e ?5 77 1511 y ? ? ????? , a.e-ue U-val.ce, 'Uv1)ra? ;ae 1,1ne a i ^^• i •(`?"'? ? -^-? ? i f . ? 6e ?e,uirt: U'Y7!ut <<zr ;no snQ :rp !ytily ne!'*nqS less :-an AnG 1i+a S is 1eu vian tIr.E S, pr;,azet ss.tr.D ; let lee: _oet ? tS. :f t:nf 2 rS qrta:or :emn dent 3. D? linf 7?r•.i:l• :t.dn i,n! '?•,^?:n lt!e^+:Af a1::-qa.+ 1-ra`-4c for totdt txur,tr sa.e'cos. 4u1 'l:^? 1) ?:1zA 'l?:+e G), ; 1 y I s,ss .L;.?e I> ? U•??ive L,^e )? ¦ { ? ? J ? ? 5,ea ? i : imf 2 + ? ?!1f ? ?r-"w I ^ I, ? #Zoo(ol ., : ? . ; j lteusLl telliag/ltoe! Tasulatsd Assa: Z Z 4q. Tt. (+riLh attie area) R-valum r-- :nce[ior als Fila .61 ? ?asulaciaa 4-?; OD j Coc[iauoua 'apoc 3arzios 0.00 ? *.aterior r!aisa •5 ? ! Iacgr!oc A.ir Fila .61 ? Tocal.;.saembly 3-oalue ?ssembip C-Va3ue (1/it) Late* on ?a3e 1 7 '3ure 2 Ceiliag/ltooi Framing Azea: Sy. Ft. (+ich accic area) A-Va1ue ? ! iatarior Ur Fflm .61 : Icsulat:on 33,5 ; %:ood `!eaber ? Cuntiauous :*apor 3aTrier 0.00 I :ace?lar eiaish 'S& i ! :acerior Air Film .61 Total ?ss?biq R-4alue 3 ,? s a4snmblY C-L'a!ue (1/R) ' Q ZyL Eater oa Page 1 Por addi[ional rxf asafsbtias, $se paqea 7 and B. . E ., Fir. tA c.:ISas/Uor tnaulacad sru: L R sa. Fc. (vichout atite at") a-Qalue vesced Air Spaee . Incsrior ais EiL .61 ! ,:su2acloo 30,OU Conc:auoua 7apor 4arriar 0.00 :ncer:oz Finish t5(& Lneartor Air EiL ,61 70ca2 A.ssembly Et-value A.sse=bly ;;-Value (1/a) :n*_ar -in 2agt 1 riQure `.a CeilingiRoof Framing area: Sq. Ft. ?,(vithout actie area) ,.y R-Va.tue ? Exterior air Fila .17 locfiag ,144- i 3ooE Sheaching ? ?ood `!emhe* L Contizuoue ?Jaeot 3arrler 0.00 Iatericr riaiah 1.5& Lacariar Air Flla ,61 I '.atal kaseab:y $-Vala* , v 3.sse-bly C-74lum (l/!U • 011 ? Eacer on Page I For addic:cnal toof aasemblies, sk paqes 2 and 8. 3 . , f!_ 7 tW:od We11 toffulaemt A.rsa: I Z,S7 sq. rc. R-vaiw 2ncerior A.is riL .6A Iztttior °inish ?k'? Conci_uous ^apoc Barsiee 0.00 Insu'_stiaa L •p C) Exc:rior FinisD '47 Exterlor 3ir rila .17 i i Totai Xssemblv R-valua XSSexb:q G-'JSlue f1JR) Eacer oa Page 1 • wr? Figure 4 Ezeoeed Vall framing Ares: 1 a0 Sq. Fe. B-Valcsc Iaterior ?,ir rilm .58 I Iacerior Fiaisn ?y 5O. Ccncinueus Capor Bazrier 0.00 I .ood !!ember _yy?r Sheathing Exterior Einish Excerior Afr FiLm .!7 Tocal assambl7r fl-Value :'asembly C-t:alue (1/x) ' 107 =16er on ?age t !or addlcional w:ll assemblies, see paqe A. ? Ti?r? ! Psaos?d Va1.2 RSA Joiat Asss: zo ISq. lt. q•ralw Zacsrior Atr f!L -N Vapar 9trrieT 0.00 Ia?ulati? ?; ?J 0 , 'lood `!embtr ! Sheach3ng ? ' S 1 E[:Gr:4L e iIIS3h ?V I E.xcsrior Air FiSA .11 Tocal A.99embly R-value .Assembiv ',;-Vatus (1/8) Eater oa 2age 1 Yotes: 1) Ploors over uaheated spaces`. Por floors of t^.ese*d or aochanically cooled sQaces ovez ur.heated spaces, the ovesall L'-value, far the [loor sLs1I eot exceod 0.05. For floocs ovot out3oor , aiz, such aa overlangs, ehe overal2 C-Jalue for t!ie floor shall aeet the same requi:ement as Cor coots, a-Ja2ue of 0.04. 2) 52ab-on-qrade Iloors. For alab-an-qrad*,-t.*.G insu2ation arounG th* parime!er ot eho axpoaeQ lloor tka:l .`.ane a minimum I-vala* o[ 6.4. Thf insulatfon must ex2and 3ovnvard fram the Cog ot the a:ab a minimum o[ 3'6' ar 3ov!:war3 to the bottoa oi [ha slab Lhen horizoneally beneat4 th• sIab fot an eqvivalent distance. 3) vapor barr£crs. Tifo maximua pera rating foc the vapor harrior is O.I. Aminimum ot 4 mil polyethelina, or equal, ia required to achieve this. Thi vapor Sarri*r muet ba coneiauous rith all joines overlaEped and made over :saminq membars or alxkiaq. 4) For notes on taundstion wall see rsqe 6. S) For additional sssamblies noc illustraced uss .orksheat an paqe 8. 5 ; '' ? • ts?iis• d [s?oeee ro?mise:oa ?li Ass? Coaeraea Q1ae2 os ?oured ,?r 7 • woe?d FoundaLfoe Iaiulaemd Coacrecs Fo?daLias itrsa? ,_ 3q. R. Ar•a: sq. K. R-value Interiot Ais Fi2m bg tanc!nuous Vapor Darrier 4.00 fouadatlon Val: :nsuiatioa E,ccerioc Air Fi,a • Z 7 7oc:l ksseTblr R-value 3A Assemblv U-Value (1/fl) ' V7 (c Enter on ?a;e I I )nlr ch* ibove ;rad• &n a 3f cN• !oun2aci.n •a:: :s :o !• :ac:_dRa :a cie r..sr;r -at.j iat:aaf. cr.o '1• En.-[? 'zaa crqui:fs c`•as. :f a-n oor iearo tafasent n ::,%rl ipau is aac -r.9ut4ced, :s• :::.nea• :ica i:I iusc Z• :asulatrd_ Eitkar -1• c.unGa[:;n •ust ?ar• a iiaiati; 3-W iafulst::n ?pe::ed r'-a er.• c:v ot :no f_?.ne.c-z. '7 :Sf ?'C7C -:'• 3: s ii:,:mu. i-'s iafu Ut:on cpplitd aver •:• !%c: ni.undat:3n •ali. 7S0 2-7slue s;ee:c=*d u `?r :`• :^Iulac:oa taurial aety• .. (i rid?ii ::ii °-?3'sL3LC?A '.s :o :• ?pet_?Q •? .?? •st&rwr af :?ts ?:::ada!:-a ?a1I. c'O aoova ;ra3• aor;:on susc :o pr3:rc:ed ?na cni ;4a, s•`.• -sa:ner i,a Pnr+jczi aeuu. ll :C r:lstd f:ts :afuiiC::n if !o y• ie:lcv4 e] tSe :ntat_qr. ie -Auat So }roceccsi Sw +i1:a y t-' t+?. oosrd 3r eaaa; :av epec.c:ed :a s*t:szn . .. 2f :ne :ni`'J-% )u::1:af :AAi. i1 ;^_uaQat*.2e .al: :z2u11tion :'3r w od E?vndlt::ns auSt :t :asti1:eS u ,a?c:c:sd yr s!!a =ar:t: 7raduc:i kisac:sc:oe'i ?*aLP vu uat. O t 700 ? u ? O o ^ zwQ ^„? ? p??Q? ?fye'?D e t:ood Foundacion Eramed ?.rea: SQ. ft. R-Value incerios Air F31n .6 Concinuous Vapor 8arrier 0.00 Faundation Vlil ::jood) %:aoQ Yenb E ior Air Fil. l7 Tocat Assemblr R-t'alus f.aatmbtr U-vilus (t/R) Encer on Pag! t L SI[yUGMt, wtNOCIM an0 70QR sSStUttlL:ts , ?'? -70._ - -- --- --- -- - a.: ? ?s,+oia?.,, ? '?+rrs. w. ! +.. ??.e '?d s.sn ?ra ?, ? a•vvu. ' ?.?1: R ? . ? (, xz, y? t`F? ? , 7.8 ?? ? ; ?c7?:?wz... ? t ? ??? i ?,! ' •'?7 ? 3?`?.? ? ? ',?v,? c r? s+= I I I a ? ?-- !•?" I !?S a- ???n ' Sits Ia Usod 'sst :es 4ns 'Ai R-valus 7aer !a•rLU? n-.uM Sta+? 7es i ? 7e? U3Od ? SnenelY' U•VSIm 4=li? Jz? ??f!i ?{v'i.???? ? f - f ? ?1•'/ r I?? ? ( ' i '{ ? ???./4 ? - ' y a ,Zrs_i ? , ? tlr8 ! ?,tl ! ' ! ?Iy3 I_i.?9 sII . I u-at:an ? I i I W•44lw j zif .v?nQar ? uanurac:•r Wr•:rac-.r? ?o. I Ve. Us?d 'aal Safh APtf A) I R-vaiy ? Af1D? ^r?? i ?a2C'1 ? 1 ? 3,i? I, j ? .U;:? ? •?e 5? . ., . •- . . , r. ?it 4tl.T rIvLm iSl?;-Yi S i 1 4 ? ? I I f ! I }•••0-tIF t 771W 'VitlA _a90 1Gt ! C.LC? ir ;,:iR •YilLw q ? '42+ as;:a,+ct f 71114 dtss?-%ro? ?'i+u ? ? __ ,r W? ?esc?? R+cnaas? - a?ca F ? I - JaummVie'vilms :."i, Cal?? r " ? •rL1! ?! ? ? 7O1 Si?l ? , ? u _+sr es, ? ? ?ct?uss - r ?, r ' i I , E I j ? I : ?a1 s3r-^?• < n. smr+Ga i '?SIeRGv . '•IJ?Jt ,. r-t Y ?I . iQf . ? i 1 1?im I i ? ? ? et?A v ??::1o -t! 16i i ' ? n Z7n1 •?lla :M Qf ? ? 3m-I3I -d-Llv ? .7 48.Sw1C-t I? ?tts^a4Y ? .?; Vcr Vn ?saro+r ?s ar.1 ?esa??t . ?rt?cYnest: .-?a1?a I ? ? i Irtf+Q su F-ItT i•vuw ?149 -iea + i 71 ri 1a C7:!1 '+i/J :• i i sse*ot• :w*a+ a• ccarsa •? f ??,'? .• ?: . ? . ' araS1411OGtOa COua1v •u+?ING ?EAAI1rvEhT RtJN%%tB 3[SiGll 7W NQ OA tG J0A AOC*ESS wE?TTNG CON'R.?C'3R PMOR? 6UiLS1NG COMTIUC'OA aMOKL 'Na Saiic ;nfM I .W W*w +aast !8 17tRaiMd 4sw Ts :ilrjaierts tAd Arts aaorngd ?y *s Suiidiny :emar"aR 's ft svtis-.?t 'o !a '.wit. "1 . Ss. 'as ?l oc?at .a1! v-0 abaw Xa& , : "U' a 82 kqea la;qn :ir..-.4n:n. 'W2. S0. 4m 3f :ifliny 3lu ! "lio t $Z. 3. Sn. 4s of We-v: 1ar 3. s. Ss. 4es ot .aII ua ??= gad? . 6. S. Lln. t. if inllltreian b windo?? r'_S) Ig 1. C 87 : 82 ea4ee? . 6. lin. R. of nR1??tion i loon a Q.231 ? 0.08) ? sz ?... , 7. Lin. R. vF ;nRltration S WOtng *mrs : ;.75) v a.081 s 82 sog a. ?Iloas++cs b titC+? t++Q `aitli !irt! . ? tit=+a+ !ana 3600 6TU ?s. • sac+ %ns 1204 8TU a, 4. ?Ilo?ss?ct %r ??sisca + 24' es 326 41,000 Stu a. ? • 34' to 42' 11,300 97U u. • 42' 1, :arpr 31,500 9TU a. 10. ?za? 3T'J lew ?v ift :eo.t tar•ti 11. Add S• :an0?o:i? a?r !S8t 1722l-(.001) ¦ ?K ies? aDeve, ;.6731 ? 82 :vva. =2. Aed 'XW rnn, lo s+e lv 13. M+ilmer. ?RcVas• at?e.att. ?y SaC 6007.1=ir 12 : 1257. Q'e---1't Sin ef 4a-rau st+aq !a!1 bexae+ Unt 21 sid tinw 13. 1'r4$ 4 1* sirr '4+roca yai st+ould 1sa in Otii taucus. tIM :adr doa aJtoa ra :e am ft nat s;u :va,l- aol?t Wft,QI," %Prat ioaaae,ate eau1a"a1 ;s !qt -mmGflr anila6N. TMe ndei:prled, u aaslic.anc a ?42WAg m*it. 'sembS alRMs c1e Lba" .n?an?con ?as bren aenarv! !y ane a* -IenMt, a u++dr .riS G;rst!ay 104201 actr+eaiedes ft Rien+M;s+ 2 n:araes V+1 teauce: Wd 16,01 sOK7 Jfif n(sm"en •0 AyiAQ a1Wta -n tmOm 7( d1o Nfiti? Pw-nd Amiriian, "10010sed vm7Cf t1?; C'70O1sQ ;J'a" '110" r10.: ? sV7ut *1iklC ?SR SN?! ..sp _ 2/25/0] Watcr/Wastewalcr- IS F51.31 J?L Compliance Inspection Form for Existing Minnesota Pollution Individual Sewage Treatment Systems i%a_wr Control Agency :omplefion o( this (orm lullills !he minrmal requiremenfs of Mrnn. Stat. § 115.55 (2001) and Minnosola R. ch. 7080 (1999). Plcase refcr o local ordinances (or other requirements or information especially for compliance requirements for bedroom additions 3eneral• 3ate of Inspedion: y /O - U6 ?roperty Owner(s) ? l1 I t clY I 'erson requesting inspedion -1 Telephone (Ls>I)'??4-• 33?3L> Telephone (&51)0 ! -14-22 ;ite Address IOlr LG kCW DUfI, 1{'1 jlS Rd• City E(lll A Yl Zip Code 55123 =ire No./ Parcel No. County DA k C}'G(, Township Eal a t'1 egal Description 2`7 tl P. 1`) NI S. -2 L .ocalRegulatory Authority EUn )ate system constructed 1140 System in Shoreland Area: yes(]jq-? System in Wellhead )rotection Area: yes i!?)System serving a MDH licensed facility: yes 6_?Iocal Permit #(if any) Systems built prior to Apri( 1, 1996 and not located in Shoreland or Wellhead Protection Area or Serving a Food, Beverage or Lodging Establishment Is the svstem an imminent threat to Public health or safe ?(a yes answer is an ITPHS sysfem) - Discharge of sewage to the ground surface? YES NO Discharge of sewage to draintile or surface waters? YE5 Sewage backup into dwelling? YES - Situation with the potential to immediately and adversely impact or threaten public health or safety? YES NO Is the svstem failing? (a yes answer is a failing system) - Less than TYVO feet of vertical separation between system bottom and saturated soll or bedrock? Y E S NO ? - A seepage pit, cesspool, drywell, or leaching pit? YES N6 Is the system non-compliant7 - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2) YES N? !f yes, - Has the required monitoring taken place? YES NO (lf no, !he system is non-complying) Systems located in Shoreland or Wellhead Prote ion 7 reas or Serving a Food, Beverage or Lodgi Establishment, or systems Built after March 31 1996 is the svste an imminent threat to a lic health or safetv? (a s answer 15 an ITPHS syst&m) - Discharge of sewa e to the ground surface?/ YES NO - Discharge of sewage o draintile or surfac waters? YES NO - Sewage backup into d Iling? YES NO - Situation with the uotentiN to immediatklv and adversely impact or threa[ public safety? Is the system failina? (a yes - tess than THREE feet of vertica sep system bottom and saturated/ oil or i or YES NO is a failing system) n between II, or teachi pit? - A seepage pit, cesspool, Zliant? Is the s stem non-co - Is the system re lated under a moni operating perm7dmc no, go to page 2) It yes, - Has the requi nitor ing taken place? (I( no, the sy?m is non-complying) YES DJO YES NO ng plan or YES NO ES NO Ooes the monitoring indicate that the system meets - Does t monitoring indicate that the system meets performance expeclations? YES NO pe ormance expectations? YES (!f no, fhe system is non-complying) (1 no, Ihe system is non-complying) Reason for inspection: FYO?.CY}V? TYllmfa- Page 1 of 2 wq-wwists4.31 Property Uwcicr(s) Fu(: No./ #'arce! Nu. _ . 'a.. Svstem Comuonents (Please describe the system components and attach site sketch showing systeit? locvLion): ss> b r? C,? 1?10??r - Wha t methods were used to make Gh e de terminations for the comaliance insa_e_rAioh7 (Note: No standard protocolexists. The fodowing /is[ is not exhaustive, orln seqiienfia/ order nor indicates which combination.s may ncressary fo make,7 deternrinationJ WateKight tank(s) Hydraulic Functioniny Vertical Separation Distance 0 Probed tank bottom 'n Searched for surFace outlet i? Conduded soil borings l l t Depth to limiliny laycr ?. y Fr- ? Observed low Iiquid level ? es ic Performed hydrau U Examined const. records 0 Searched for seeping in yard Depth to system bottom ? Examined empty (pumped) tank ? Checked for back-up in home u [xamined records ? Probed outside tank for "black soil" ? Excessive ponding in soil system/D-boxes U LGU Limiting Layer Verificalion ? Pressure/vacuum check Cl Homeowner testimony o Other o Other v Examined for surging in tank ? "[31ack soil" above soil system o Other_ Status of the svstem Based on the compliance criteria, the system status is: (check one) ? failing (to protect groundwaler) ? an imminent threat to public health or safety (ITPHS), ? non-compliant (monitoring issue) 0 compliant (none of tlle 3 previous conditions). Therefore, this document is a: iM Certificate of Compliance U Notiice of NoncorTipliance Is this system an EPA Class V Injection Well? ? yes 4D no Certification I hereby certify as a state of Minnesota licensed Inspedor and/or Desiyner I or Qualificd E'mployce Inspector and/or Qualified Employec Designer I that I conduded an investigation [hat accuretely determined the compliance stalus of this. system and that my recorded observations are accurate as of this date. No determination of future hydraulic performance has been nor can be made due to unknown conditions during system construdion, abuse of the systern, inadequatc rnaintcnance, or futurc watcr usayc. Inspector's name (print) Phone ??r? Z_qw?=`_?'UUq-?---- Licenseand/orRegistretionNumber JU9"? Address Empioyed by Y1 ? I ? Address Signature? ?? - -_- -- Date Uaclrade Renuirements [denvedrrom M;nnesora srarures y1ls.ss> An ITPHS must be upgraded, replacEd, or iCs use discontlnucd within tem months of receip( of fhis nofice or wilhin a shoiter /xriod i/ repuired by local ordinance. If the sysfem !ails to provlde sulTicient groundwater proteclion, fhen the system must Ue uAyraded, replaccd, or iLs use disconlinued within the trme requlrad by rvle or fhe loca/ ordinance. If an existing system is nof faUing as deflncid in law, and has at least t wo feef of design soil separation, then fhe system need not be upgradcd, repaired, rePlaced, or i_n use discontinuerJ, notwrfhstanding any local ordinance lhaf is more s(rict This does not apply to systems in shorelartd areas, wrllhead profecYion areas, or lhose used rm mnnection wifh food, Geverage, and lodging eslablishmenls vs deTrned rn law. Suggested Attachments 1) Site sketch could also include: well, well setback to system, dwelling or other buildings, tank(s),reserved soil treatment area, surface water and soil borinq locations. Include as-built drawing if available. 2) Soii bo(ng logs, showing each horizon. Indicate the texture, color, redoximorphic features depth to bedrock, stan(liny waLer and whether the material is fill. 3) A list of any and ail requirements of the local ordinance that are di(ferent from the state requirements referred to on thi; form. 4) A homeowner survey of system performance, signed by the homeowner as being fadual. 5) Monitoring dala as appropriate. Page 2 of 2 5oi( t3oring Log M Date: `7'- /l/ ' 06 r'rv?e?;i Locacion: Client:_ !i(jle &rlffimCY Address: CitY Statn BOnf1 method: au er Pit ZiP Probe Other eoring Number ?.S /.? Surface Elevation Soil type at system depth: Texture Color 3/ ?G r IO -2- 3 , / D D < /? yl --- 4 --- 5 --- 6 --- 7 --- StfUCtUfe: Blocky Platy Pris matic None Slope: % / End of boring at (a feet. Standing water table: yes no Present at feet of depth, hours after boring. Mottled soil: Observed at r feet of depth. N /Dy?- ot present in boring hole Observations and comments: Borings made by: GAi'Y U ' 104,3 Lic. A Color classification system: nnunseu otner Boring Number Surface Elevation Soil type at system depth: Depth Texture ColOf ? ir__.1 1 --- 2 --- 3 --- 4 --- 5 --- 6 --- 7 --- StfUCfUfE: Blocky Platy Prismatic None Slope: % End of boring at feet. Standing water table yes no Present at feet of depth, hours after boring. Mottled soil: Observed at feet of depth. Not present in boring hole Observations and comments: ?T- druin r_i?Qfc? Ta I',/K 0 S 15? L-?] Sq- f1 2/25/02 Water/Wastewater-iSTS9.31 Compliance Inspectian Form For Existing Individuai Sewage Treatment Systems Minnesota Pollution Control Agency Completron of this form fulfi!!s the minimal requirements of Minn. StaL § 115.55 (2001) and Minnesata R. ch. 7080 (9999). Please refer to local ordinances for other reauirements or information, especially for compliance requirements for bedroom addilions General: Date of Ins ection: ? P ( ` 9?- 07 Reason for inspection: Property Owner(s) Tele hone P (6-1 5-'(. Person requesting inspection Telephone ( ) SiteAddress g?-City ?? ti ?., ?? Zip Code Fire No./ Parcel No. County .,?2s 1v,fe' Townshi - ' p - Legal Description Local Regulatory Authority _ (? V`< _j --- /l A 4 ?` , 2 C` nr Date system constructed System in 5horeiand Area: yes Oo System in Wellhead Protection Area: yes no System serving a MDH licens ed facility: yes no Local Permit #(if any) - Systems built prior to April 1, 1996 and not located in Shoreland or Wellhead Protection Area or Serving a Food Systems located in Shoreland or Welihead Protection A , Beverage or Lodging Establishment reas or Serving a Food, Beverage or Lodging ? Establishment, or systems Built after March 31 1996 Is the system an imminent threat to aublic health or Is the svstem an immine t th safe ?(a yes answer is an ITPHS s st n reat to oublic health y em) - Discharge of sewage to the ground surface? YES NO or safetv? ( yes answer is an ITPHS system) : - Discharge of sewage to draintile or surface waters? YES - Discharge of wage to the ground surface? YES NO - Sewage backup into dwelling? YES - Discharge of s age to draintile o surtace waters? YES NO - Situation with the potential to immediately and - Sewage backup to dwelling? YES NO adversely impact or threaten public health or - Situation with the otential immediately and saFety? ? adversely impact thre en public health or YES safety? YES NO Is the system failina7 (a yes answer is a fa!ling system) - Less than TWO feet of vertical separation betw Is the s stem fail'fi . a yes answeris a failing system) een / system bottom and saturated soil or bedrock? YES - Less than THREE feet of v tical separation between system bottom nd satu t il ? - A seepage pit, cesspool, drywell, or leaching pit7 YES ra e so or bedrock? YES NO - A seepage pit, eesspool drywell r leachin it? ? , , , g p YES NO Is the system non-comoliant? - Is the system regulated under a it i Is the system non-cotnoliant7 mon or ng plan or operating permit? (if no, go to page 2) YES NO - Is the system regulated under a monitoring plan or operating permit? (if no, go to page 2) YES NO If yes, If yes - Has the required monitoring taken place? YES NO (If no, ihe system is nai-complying) , - Has the required monitoring taken place? ' YES NO (If rio, the system is non-complying) - Does the monitoring indicate that the system meets - Does the moniloring indicate that the system meets performance expectations? YES No (If no, the system rs non-complying) perfonnance expectations? YES NO (!I no, the system is non-com 1Yin ? P g) Page 1 of Z wq-wwists4,31 *Pl' 44tJ Property Owner/s V )_ Fire No./ Aarcel No. (P se des,c?ri ?0/2 c the system attach site sketch stiowing system /ocation).• l ? .. /J What methods were used to ake the det rminations for the com liance ins ectiona (Note: No standard prp[ocoi erists Tne fol%wrng lrst is not exhaustive, ol- in sequentia/ order nor indicates which combinations may necessary to make a determination) Watertight tank(s) Probed tank bottom ? Observed low liquid level 0 Examined const. records O Examined empty (pumped) tank L! Probed outside tank for "biack soil" J Pressure/vacuum check o Other Hydraulic Functioning ?r Searched for surface outlet O Performed hydraulic test ? Searched for seeping in yard, ? Checked for back-up in home Cl Excessive ponding in soil system/D-boxes ?` Homeowner testimony ? Examined for surging in tank o "plack soil" above soll system ? Other Vertical Separation Distance ? Conduc[ed soil borings , Depth to limiting layer , 4er ! Deptli to system bottoni A_;?' --I Jv Cl Examined records U LGU Limiting Layer Verification ? Other eased on the comp(iance criteria, the system status is: (check one) ? failing (to pr tect groundwater) p an imminent threat to public health or safety (ITPHS), ? non-compliant (monitorin9 issue) compliant (none of the 3 previous conditions). Therefore, this document is a:?Certifcate of Compliance Notice of Noncompliance Is this system an EPA Class V Injection Well? ? yes W no Certificakion I hereby certify as a state of Minnesota licensed Inspector andJor Desiyner I or Qualified Employee Inspector and/or Qualifiecl Employee observations Designer I that are I accurate conducted as an invzstigation that accurately determined the complianc status of this system and that my recorded o f this date. No detennination of future hydraulic e performance has been nor can be made due to unknown conditions during system construction, abuse of the system, inadequate maintenance, or futwre water usa9e. Inspector's name (print) _ Phone65,_:/ License and/or Registration Number Address Employed Address. r ? ` r Upqra e R2g ment5 (derivedfromMinnesota5'tvtutes§JI5.55) Date An ITPHS must be upgraded, replaced,, a its use discontinued within ten months of receipt of this norice or within a shorter period if r2quired by locv/ ordinance. If tne system fails to provide su?ciei?t grou??dwater p?otectinn, , replaced, or i!s use d?scontinued Hvithin the then Che system must be upgraded tin7e required by rule or the local oidinance. If an existing system is not failing as derined in law, and has at leasr two feet of design sorl separation, then the system need not be upgraded, reparred, replaced, or ifs use discontrnued, notwithsfandinq any Iocal ordrnance thaf is more sfrict This does not apply to systems in shoreland areas, wellhead protection areas, or thosz used in connection with foocl treverage, and lodging establishments as defined in law. Suaaested Attachments 1) Site sketch could also indude: well, well setback to system, dweliing or other buildings, tank(s),reserved soil treatment area, surface water and soii boring locations. Indude as-6uilt drawiny if available. 2) Soil boring logs, showing each horizon. Indicate the cexture, color, redoximorphic features depth to bedrock, standing water and wheth2r the material is fill. 3) A list of any and ail requirements of the local ordinance that are difFerent from the state requirements referred to on this form. 9) A homeowner survey of system performance, signed by the homeowner as being factual. 5) Monitoring daia as appropriate, e Page 2 of 2 CityofEa�all 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 r Use BLUE or BLACK Ink For Office Use Permit #: Permit Fee: Date Received: Staff: 7'i'-(3 467 2013 RESIDENTIAL BUILDING PERMIT /�APPLICATION � Date: � Site Address: 04 ckt/4-1-0 0 Unit #: Name: /K wc.� �.ey'� Phone: 44 5si '8l Address /City /Zip: qOt, /4416.-ErS' attgeL Applicant is: Owner )(Contractor Description of work: Construction Cost: 10,440 o, t4O t Multi -Family Building: (Yes_ /Noy ) Company: EI, S r Ir` %4t, Contact: c ct✓rl CY S. �1% Address: 1??/ 3 1 16-c City: alACn f`QlIS State: $11) Zip: c6009 Phone: (vi2-- /22-- License #: 6C20 73 Lead Certificate #: If the project is exempt from lead certification, please explain why: (see Page 3 for additional information) COMPLETE THIS AREA ONLY IF CONSTRUCTING A NEW BUILDING In the last 12 months, has the City of Eagan issued a permit for a similar plan based on a master plan? _Yes _No If yes, date and address of master plan: Licensed Plumber: Mechanical Contractor: Phone: Phone: Sewer & Water Contractor: Phone: NOTE: Plans and supporting docu-. the information may be classified ents that you submit: are considered to s non-public if yc a provide specic real conclude that, they are trade secrets. CALL BEFORE YOU DIG. Call Gopher State One Call at (651) 454-0002 for protection against underground utility damage. Call 48 hours before you intend to dig to receive locates of underground utilities. www.00pherstateonecall.orq I hereby acknowledge that this information is complete and accurate; that the work will be in conformance with the ordinances and codes of the City of Eagan; that I understand this is not a permit, but only an application for a permit, and work is not to start without a permit; that the work will be in accordance with the approved plan in the case of work which requires a review and approval of plans. Exterior work authorized by a building permit issued in accordance with the Minnesota State Building Code must be completed within 180 days of permit issuance. x Dot Jodi NW 0'66 Applicant's Printed Name x Applicant's Signature Page 1 of 3