Laserfiche WebLink
UNIVERSITY OSTP Preliminary Evaluation Form UL <br /> OF MINNESOTA <br /> 1.Contact Information v 05.13.14 <br /> Property Owner/Client: Lindsay and Anna Klombies Client Phone Number: <br /> Mailing Address 1000 Willow Dr.South,Orono,MN 55391 Project ID: <br /> Site Address Same Legal Description <br /> Parcel ID:I I Latitude Longitude <br /> Evaluation for system type ❑New cons.... (DReplaoenert Date October 9,2014 <br /> 2. Flow Information <br /> Client-Provided Information <br /> Type(s)of use(all that apply) ❑'Realder" ElCam1vdal ElOtic(wry) <br /> No.of bedrooms*(if applicable) 5 Unfinished space (ft') <br /> No.of residents in home Adults Children ETeenagers <br /> Existing flaw measurements [Ives(if Yes,attach readings) ❑No <br /> ❑G-age Disposal QW.WSafonur' 01=Fillin <br /> Water-using devices(check all that ❑'Dirtwsstar oswro Pmp• Other(specify) <br /> apply) ❑large Badbb/7aom1 ❑High-dency Funace' <br /> ❑WrKkyAmge Tub on 2rd Roar Elliot Tub* •Clear water source <br /> Water use concerns(check all that ElFaucWrold Leals ❑halaple team of tnadry/Day ❑tang-T. n Paargmh Nem []use of ahu-eaetr w soap <br /> apply) ❑LrHorm&mina; E]No lxx saes, ElFrsphsx Eniardadng of goof-Town Gusts <br /> Any additional current or future uses on this parcel(specify) <br /> Any non-sewage discharges to system (specify) <br /> Sewage ejector or grinder pump in home? ❑vas E]No <br /> I acknowledge the above is complete and accurate (Client(s)signature and date) <br /> Designer-determined Flow Information <br /> A.Estimated Design Flow(gallons per day) 750 <br /> Anticipated waste strength values: ❑�Dor"eetkSb,.ngth 0HI9h—Vth BOD: mg/L <br /> CBOD:�mg/L (TSS):E:::�mg/L 011G:�mg/L <br /> 3. Preliminary Site Information <br /> B(1).Water supply well(s)within 100 ft of absorption area ❑Yes QNo <br /> Well(s)were located ❑Died Obsw4won ❑Canty Wall Index M" ❑personal cannon°tion MN Unique Well Id 1': <br /> Depth of well(s) 1 112' ft Well casing depth(s) 112' ft Source Well Index <br /> Impervious Layer 13NO Dye If Yes,Define Et Source: Required Setback: 50 it <br /> B(2).Site within 200 ft of noncommunity transient supply well Ely's E]No Source <br /> B(3).Site within a drinking water supply management area ❑Yes E]No Source <br /> B(4).Location of all existing and proposed buildings and improvements on lot(see Site Evaluation map) <br /> B(5).Buried water supply pipes within 50 ft of proposed system []Yes E)No <br /> C.Location of all easements on lot(see Site Evaluation map) Source <br /> D.Elevation of ordinary high water level(OWHL)-MN DNR(if adjacent to parcel) <br /> E.Floodplain designation and food elevation Source <br /> F.Determine property lines(see Site Evaluation map) ❑sa"w ❑tet Mop 20d.: Hennepin County GIS <br /> Site located in a shoreland district/area ❑yes ❑Q No <br /> G.Distance of setbacks Oma Unes ❑ONwL ❑wooer suo*Fppns <br /> ❑qhs llul lings ❑F ❑-ilis) <br />