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UNSER (COMPANY IN if, <br /> Septic Designs—Compliance Inspections—Operation&Maintenance—Trouble Shooting <br /> Soil Borings--Percolation Testing—Site Evaluations <br /> Minnesota Pollution Control Agency Licensed and Bonded <br /> St Cloud Area Alexandria Area <br /> 1600 23e St 2753 Le Homme Dieu Heights NE <br /> St Cloud IVIN 56301 Alexandria PIN 56308 <br /> Business: (320) 248-2262 Business &Fax: (320)763-5577 <br /> www.cwlunserco.com Email: clunser@hotmail.com <br /> Preliminary Evaluation Form <br /> 1. Contact Information <br /> Property Owner/Client: Matthew Katterhagen Date: 10/5/2017 <br /> site Address: 3425 Watertown Rd Orono MN 55356 File#: SDI000317 <br /> Email: Phone: <br /> Mailing Addr. 1405 Olive Lane North Plymouth MN 55447 Apt.#222 <br /> Legal Description: <br /> Parcel ID:1 3430010 <br /> 2. Flow and General System Information <br /> A. Client-Provided Information Construction ❑Replacement <br /> 1. Project status: ❑ r]Repair or Expansion <br /> 2.Type(s)of use: ❑Residential ❑ Other Establ: ❑Other. <br /> 3. Residential use <br /> a. No. of bedrooms: E= <br /> b. No. of residents: 2 Adults 2 Children Teenage <br /> c. In home business(YIN): I If yes, describe: <br /> 4. Water-using devices: ❑Garbage Disposal Q Dishwasher ❑Hot Tub* <br /> (check all that apply) ❑Sewage pump in basement 0 Water Softener* Sump Pump- <br /> P]Large Bathtub>40 gal ❑iron Filter* Self-Cleani Humidfier in Fu e* <br /> 0 Washing Machine 0 High Eff.Furnace* ❑Other: <br /> Clear water source-should not go into system <br /> 5. Additional current or future uses: F none per client <br /> 6. Anticipated non-domestic waste: none per client <br /> I acknowledge alt homeowner/client info is eongAete 8 accurate: Client Signctttlre Ft Rate <br /> B. Designer-determined flow lnforrnation <br /> Estimated Design Flow 600 gpd Anticipated waste strength type: Domestic <br /> BOD: 125 /L TSS: 60 mg/L OiLftGrease: 20 m /L <br /> 3. Preliminary Site Information(see attached soil survey info for soil map units, landforms,slope ranges,etc.) <br /> A. Well information <br /> 1. Water supply well(s� ithin 100 ft of abso tion area(Y/N) Yes #of wells <br /> Well(s)were located LJ D>�Observation ��nty Well Index Maps ❑Personal Cemmuniption Unique well# �111�014Depth of wetl(s) 163 ft Well casing depth(s): 159 ft Source l log <br /> Impervious layer Yes,define&source: No I Required setback:59 tank(s)50•drainfield <br /> Additional info regarding multiple wells: <br /> 2. Site within 200'of noncommunity transient well(Y/N) Yes,source: n/a <br /> 3. Site within a drinking water supply management area (Y/N) Yes, source: n/a <br /> 4. Site in a inner wellhead management zone(Y/N) Yes, source: n/a <br /> 5. Buried water supply pipes 50 ft of proposed system (Y!N) Yes, source: owner/client <br /> B. Site located in a shoreland district/area NNn/asource: <br /> Source:Roger Peitso City of Orono Building Official <br /> C. Site located in a floodplain Source:Roger Peitso City of Orono Building official <br /> 1. Elevation of ordinary high water level source:Roger Peitso City of Orono Building Official <br /> 2. Floodplain designation/elevation(10YR) Roger Peitso City of Orono Building Official <br /> 3. Floodplain designation/elevation(100YR) Source:Roger Peitso City of Orono Building Official <br /> D. Determine property lines and ID on site evaluation map, source: ❑Plat Map ❑Survey ❑owner ❑County GLS <br /> E. ID distance of relevant setbacks on map: ❑Water Supply Pipes ❑Easements ❑Well(s) ❑Building(s) <br /> ❑Property Lines ❑OHS- ❑Other <br /> 4. Local Government Unit Information r Peitso 952-249-4625 <br /> Name of LGU:J City of Orono LGU Contact: Roge <br /> TGU-specific design requirements/setbacks: <br /> LGU-specific installation requirements: <br />