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r <br /> � r <br /> UNIVERSITY OSTP Preliminary Evaluation Form <br /> OF MINNESOTA <br /> 1.Contact Information v 05.13.14 <br /> Property Owner/Client:11,)tiombies Client Ptione Number:�— <br /> Mailing Address 1000 Wit(ow Dr.South,Grano,MN 55391 _..._...." _ Project N): t <br /> Site Addressi Some Legal Description F <br /> Parcel ID: Latitude[ Longitude <br /> Evaluation for system type Q tirwCmmudtm OR"Wmnent pate October 9,20i4 <br /> 2. Plow information ..,~~....~_.. <br /> Client-Provided Informal on <br /> Type(s)of use(all that apply) j7R�d Qtanvrarr el L Mee(spam <br /> Nm of bedrooms'(If apptkabte) 5 ) Unfinished space(Eta) _ <br /> No.of residents In hone []Adults Children ❑Teenagers <br /> Existing flow measurements oyes(it Tes,am" ) Ono <br /> ] W aiMpOdal owuter 5.>fanure [guar F*"- <br /> Water-using devices(check all that L.jtnshwasnw 05PUMV. Other(specify) <br /> OMY) []N;gh taadcrcy rwnuce' <br /> ❑uua,,y/tame ruoo"2nd taaar pH0 Tu' •Clear water source <br /> Water use concerns(check all that LFewVTaiet Leaks Qhaiega twds d LVxW W0" Oto-q-Tenn Fiesa"M Nods �ttsa dANFDa[6eaa1 Soap <br /> apply) plo-iieme amass ['mo n.u$seen EIRTauad en4e,M"of pa-d-roan 6ueas <br /> Any additional current or future uses on this parcel(specify) <br /> Any non-sewage discharges to system (specify) <br /> Sewage ejecta or grinder pump in home? <br /> I acknowledge the above is complete and accurate (Citent(s)signature and date) <br /> Designer-determinod Flow information <br /> A.Estimated Design Flow(gallons per day) > <br /> Anticipated waste strength values: O 56en0h awl s W4M BOD:r��mglL <br /> CBDD: nq(/L (TSS): mgtl (xG:L�Jras11. <br /> 3. Preliminary Site Information " <br /> B(1).Water supply welts)within 100 ft of absorption area 0- <br /> Welt(s)were located EIM,u coo en,~ Ucm"dy wen indar Napa up"e l cam wkaoa, MN UnitRee Well Id d: <br /> Depth of wells) s10D' ft Well casing deptb(s)( '100 .._ft <br /> Impervious Lv/er [lift Dor H Yes,Define a Source: r Required Setback: <br /> 8(2),Site within 200 it of noncommunity,transient supply wall Ely's Rift Source--1 <br /> B(3).Site within a drinking water supply management area Or- )mow Source <br /> B(4).Location of all existing and proposed buitdings and improvements ars lot isee Site£wrtuation map) <br /> 8(5).Burled water supply pipes within 50 ft of proposed system (]res 0-,M. <br /> C.Location of all easements on lot(see Site Evaluation map) 5ourceE — <br /> D,Elevation of ordinary high water level(OWHL)-MH DNR(if adjacent to parcel) l <br /> E.Floodplain designation and food elevation _ Source <br /> F.Determine property lines(see Site Evatuot(on map} (NrMy timet Na(e—'Mower F __ Hennepin County GIS <br /> Site hated in a shorcland districVarea �'es G% <br /> G.Distance of setbacks ['ROMW tines [30twt Qwxsr newsy P"s <br /> C:jomer as r gs )jEas corns j]svdt(a) <br />