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IMnwmofWxr000w <br /> ONsrrE <br /> � Preliminary Evaluation Form r��TMENT <br /> PROGRAM <br /> �.Contact I�brmattan _ `. ; ' ` <br /> Prop�rty OwneNClbnt Clknt Phone Number. <br /> Addrcu <br /> Par+�el I.D. TownsMp# , ,4 I I I Range# II, �i I , ,� !�� � W Section <br /> Date TownsMp name il+��!'i �',i,W���, Latitude/Longitude I�I III �II ���I� �I�' III��� I V'I�'I�II <br /> Evaluatlon for system type New Corntruetton❑ j�xisdng Dwelling Parcel dimeruions �� i 1, � I I� I 'I��I,i �� �i�l'�y,l,,, ,I! �, <br /> u � <br /> 2. Flcw Cniarrruticn <br /> , <br /> Cliene-Provt I orn�ation �� <br /> Type(s)of use(clf that cpply) u ResfdeMial ❑Commerctal ❑Other Use(Speclty) ��I , �i <br /> No.of bedroortu•(If cpplicab/e) UnNnished space (ft=) <br /> No.of residents in home ults ❑Children ❑Teenagers �Daycare <br /> Existing flow measuremenu ❑Yes(If Ya,attach readings) � <br /> 0 Garbaae Disposal ❑Water Sottener" ❑Ir�Filter' <br /> Water-using devices(check o/!that ❑Dtshwasher �Sump Pump" ����Kr�Y) <br /> °ppry� �Large BathUib/Jaumi ❑Migh Efffciency Fumace' <br /> Q Laurxlry/Large Tub on 2nd Floor ❑Hot Tub' 'Ckar water source <br /> Water use rnncems(check all that ❑Fatxet/Toilet ❑Multi�e Loads of Laundry/Day ❑Long•Term Presciption Meds <br /> �p�� ❑In-Home Business �No Lint Scrcen 0 Use of AnN•Baeterial Soa �F <br /> P requent EntertalMng of Out-of•Town Guests <br /> My addttional current or future uses on this parcel(specf�r) <br /> Any non-sewage discharges to system (spectfy) <br /> Sewage ejector or grinder pump in home ❑Yes <br /> I acknowledge the above is complete and accurate (Climt(s)sl�aturc md date) <br /> Destyner-determined Flow Infortnetion <br /> A.Esdmat�d Desi�Flow('sltons per daYl <br /> Antldpated waste strength �Bomadc 0 High Strength Description: <br /> 3. PreBrt! Sit�.l�ormafion <br /> B(1).Water aupply well(s)within 100 ft of absorptfon uea ❑Ya �No <br /> Well(s)were located �.Direct Observation 0 County WeU Index Maps ❑Personal Commu�teation <br /> I�, ! <br /> Depth of well(s) ft Well casing depth(s) ft Source <br /> B(2).Site within 200 ft of noncommunity transient supply vrell ❑Yes [�'No Sour�ce <br /> B(3).Site within a drinMng water supply management area ❑Yes (�Pb Sourre <br /> B(4).Locatlon of all e�dsdng and proposed buildin�x and Improvements on lot(see Sfte EvoGatton rr�) <br /> B(5).Burled water supply pipes wkhin 50 ft of propos�d system �Ya j�1 No <br /> C.Loaatlon of all aas�menb on IoL(see Slte Evoluatlon mc�) Source i �I I'�, � <br /> D.Elevallon of ordinary ht�water kvel(OWHL)-AAN DNR(if adjacent to porc�() <br /> E.Fioodplain desig►atfon and flood elwadon Source <br /> F. Determine prop�rty lines(see Site EYc(uallon mcp) ❑Survey �.Plat Map �Other <br /> Site located in a shorcland distrid/arca ❑Yes 0 No <br /> G. Dlatance of satbacks ���r����s ❑oHw� p E,s�menc� �Water Supply Pipes ❑w�u�:� <br /> ❑Other Buildings <br /> H.Soil Survey Inforn�aHon(from wrb to1!su►v�ry) ❑Map AAap UMts on Parcel �� ���p'�',' 'M �� �I i , !��'��d <br /> rna <br /> List landfortns Slope Range II i I ll il la�'�II IIi�0� <br /> Parcnt materlals-check ulf that qvply Landscape Positton(check a/l that c�ply) <br /> �tu p outwasn p�oess O eedrodc ❑Alluvium p s�mmic .�.snou�aer p sacic:b�e p Foocsa�e ❑roe:�e <br /> ❑CoUuvium 0 LaasUir�e ❑Organlc ❑Gut/fiQ Q peprcssian ❑Strcam �TeRace ❑Manmade ❑Plain <br /> Minimum bedrodc depth: indies Minimum bedrvck depth: inches <br /> Maximum bedrock depth: incha Maximum bedrock depth: inches <br /> Septic Tank Absoprtion Field-Trench(MN) <br /> AAap Unit <br /> Ratings Septic Tank Absorption Field-At-grade(MN) <br /> Septic Tank AbsorptSon Field-Naund(MN) <br />