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UNIVERSITY OF MINNESOTA OSTP Preliminary Evaluation Form 1.Contact Information v 11.05.31 Property Owner/Client: '�+ ,4tE 0 O Client Phone Number: Mailing Address Site Address Parcel 1.D. Township kRange ri 1W Section Date �' _ c}Ol� Township name — Legal Desc or Lal/Long Evaluation for system type ❑New Construction Replacement- Parcel dimensions 2. Flow Information Client-Provided Information Type(s)of use(all that apply) Residential ❑Commercial ❑Other Use(Specify) No.of bedrooms'(if applicable) �Y, 1 `J p)Unfinished space (ftNo.of residents in home Adults Children Teenagers [3Daycare Existing flow measurements s(If Yes,attach readidgss)^ 13 No (K..,�Garbage Disposal Water Softener' ❑Iron Filter- Water-using devices(check all that q�Dishwasher Sump Pump' Other(specify)apply) b Large Bathtub/Jami High Efficiency Furnace' ❑Laundry/Large Tub on 2nd Floor Hot Tub• Clear water source Water use concerns(check all that apply) ❑Faucet/Toilet ❑Multiple Loads of Laundry/Day ❑Long-Term Prescription Meds ❑In-Home Business ❑No Lint Screen ❑Use of Anti-Bacterial Soap [3 Frequent Entertaining of Out-of-Town Guests Any additional current or future uses on this parcel(specify) Any non-sewage discharges to system (specify) Sewage ejector or grinder pump in home P( .� Yes j ❑No I acknowledge the above is complete and accurate I (Client(s)signature and date) Designer-determined Flow Information A.Estimated Design Flow(gallons per day) Anticipated waste strength values: *Domestic ❑High Strength BOD: mg/L CBOD:E==mg/L (TSS):E==mg/L 0&G:[:=mg/L 3. Preliminary Site Information 8(1).Water supply wells)within 100 ft of absorption area ❑Yes No Wells)were located Direct Observation ❑County We((Index Maps ❑Personal Communication MN Unique Well Id N: Depth of well(s) I > 166 7ft Well casing depth(s)I > ift Source B(2).Site within 200 ft of noncommunity transient supply well ❑Yes NC-0 Source 8(3).Site within a drinking water supply management area ❑Yes ](No Source B(4).Location of all existing and proposed buildings and improvements on lot(see Site Evaluation map) B(5).Buried water supply pipes within 50 ft of proposed system WYes ❑No C.Location of all easements on lot(see Site Evaluation map) Source D.Elevation of ordinary high water level(OWHL)-MN DNR(if adjacent to parcel) --� E.Floodplain designation and flood elevation Source F.Determine property lines(see Site Evaluation map) ❑Survey ❑Plat Map Other Site located in a shoretand district/area ❑Yes ❑No G.Distance of setbacks Property Lines ❑OHWL ❑Easements Water Supply Pipes 'W'-ell(s) Other Buildings H.Soil Survey Information(from web soil survey) ❑Map Map Units on Parcel List landforms Slope Range Par nt materials-check all that apply Landscape Position(check all that apply) TiB ❑Outvash ❑Loess ❑Bedrock ❑Alluvium ❑Summit ❑Shoulder ❑Backstope ❑Foots lope ❑Toeslope ❑Colluvium ❑Lacustrine ❑Organic ❑Cut/Fill ❑Depression ❑stream 13 Terrace ❑Manmade ❑Plain Minimum bedrock depth:11 inches Minimum bedrock depth:❑inches Maximum bedrock depth:❑inches Maximum bedrock depth:[—]inches Map Unit Septic Tank Absorption Field-Trench(MN) Ratings Septic Tank Absorption Field-At-grade(MN) Septic Tank Absorption Field-Mound(MN)