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IMrv�urtip W�upo� <br /> ' ' ONSITE <br /> Preliminary Evatuation Form TREA MENT ' <br /> PROGRAM <br /> f.Contuk IMormatlan _ , _ _ <br /> <: - <br /> Prop�rty Owner/Gtent: Cltent Phone Number. <br /> Address <br /> Parcel I.D. ToMmship# Range# W Section <br /> Date Township name I,�,' '�I I� LaHtude/Longitude t � ;��, " fs,�"� <br /> li. <br /> Evaluallon for system type Pk.w Construction� ,jj�Ekisting Dweltlng Parcel dimensions � �'��'�.�I� �� � '� '�I <br /> 2. Flow Inform�tlon : , ' <br /> CBent-Pro In ormatiori <br /> Type(s)of use(otl that�p(y) �Residential ❑Commercial ❑Other Use(Spccify) 'pi,' �' �. > <br /> �r� I i�i <br /> No.of bedrooms'(if�pplicable) � UnHnished space (ft2) u'�� - <br /> No.of resldents in home Adules ❑CMldren ❑Teenagers �Day�care <br /> Existing flow measurcments 0 Yes(If Ya,attach readings) <br /> 0 GarbaRe Wsposal 0 Water Sottener' ❑Iron Fitte�' <br /> Water-usina devices(check ol!thct ❑p�z�� �Sump Pump• Other(spectfy) <br /> �P�) ❑Large Bathtub/Jacual �High EffScien�.y Fumaoe' <br /> ❑Laundry/Large Tub on 2nd F400r �Iiot Tub• 'Clear water source <br /> Water use concems(chetk o((that �Faucet/Toilet 0 Multiple Loads of Laundry/Day �LonQ•Term Prestrtption Meds <br /> �P�� L71n-Home Business <br /> 0 No Lint Scrcen 0 Use of And•Bacteriat Soap Q Frequent Entertaining of Out•of-Town Guests <br /> My additional curtrnt or future uses on this parcel(spedfy) <br /> My non-sewage discharges to system (spedfy) <br /> Sewage ejector or gr(nder pump in home �Ya 0 No <br /> I acknowledge the above is complete and accurate (C(lent(s)si�rwtun aid date) '> <br /> Deslpner-determin�d Fiow Informatlon <br /> A.EsHmated Desl�f Fbw(yslbns per daY1 <br /> Antidpated waste atrcn4ch ❑OomesNc �High Strength Descrtption: <br /> 3. P�rllfnfnary Site lnfom7at(on ' <br /> B(1).Water wpply weli(s)wlthin 100 ft of abso <br /> ryt(on area �Ya �No <br /> Well(s)were located �ircct Obsarvatlon �Courriy Well Index Meps �Personal CommuMcation <br /> Depth of well(s) `� ft Well casiog depth(s) ` � .ft Source <br /> B(2).Site within 200 ft of noncommunity vanstent:uppy wall ❑Ya [�1Vo Source <br /> B(3).Sib within a dAnMn�water zupply mana�ement a►ea [�Ya � �u� <br /> B(4).Location of aU exlsHr�and proposed buiWin�s and lmproVertants on lot(see Site EvaGwtlan rncp) <br /> B(5). Bu�ted water suppy plpsa wlthin SO ft of proposed system ❑Yes �No <br /> C. Lxatio�of all easem�nb on lot(see Slte EvoGiet/on mqp) $ouree <br /> D.Elevallon of ordinary hi$�water lewl(OWHL)-AAN DNR(ff adfonnt to porr�l) <br /> E.Floodplain dest�natlon and flood elevatlon ' So�� <br /> F.Determine properLy Bnas(see Site EvoGation map) ❑Survey 0 Plat MaP [1 Other <br /> Site located in a shoreland distrlct/arc�a( 0 Ya ❑No <br /> G.Dlstanc�of s�tb�cks -CI RroPa4Y Lines t�� ❑OHWL �Eszements O Water SuPPb PiP� ❑Well(s) <br /> ❑Other Buildi�s <br /> a <br /> H.Sotl Survey Infornutlon(from wrb soi(survey) ❑MaD Map Uniu on Parcel 'i . �" a�y '�t,;f, <br /> Lht landforms Stope Range p y�� <br /> Parcnt materials•check aU that c¢�ly Landscape Position(check a[i tnat qpply) <br /> ❑TiU �Outwash �loess 0 Bedrodc ❑ALLuvium 0 Summit �Shoulder �Backsbpe ❑Footsbpe ❑Toeslope <br /> ❑CoUwium 0 LacusVine ❑Organk �Cut/Fi4 ❑Depression <br /> ❑Strcam 0 Tetrace ❑Manmade ❑Plain <br /> Minimum bedrodc depth: incha AAinimum bedrodc depth: inchez <br /> Maximum bedroek depth: inches Maximum bedrock depth: inches <br /> Septic Tank Absoprtion Field•Trench(MN) <br /> Map UMt � <br /> Ratings Septic Tank Absorptlon Field-At-grode(MN) <br /> sepcte'raMc absoiptton rreW-Mound(MN) #�:;, <br /> ,...;,�,,.. - <br />