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Preliminary & Field Evaluation Form <br /> www.SepticResource.com vers 12.4 <br /> Owner Information <br /> Date 11/1/2017 Sec/Twp/Rng <br /> Parcel ID 26-118-23-41-0014 LUG(county,city,township) City of Orono <br /> Property Owner: David Gange Owners address(if different) <br /> Property Address: 1140 Wyndmere Rd. <br /> City/State/Zip: Orono, MN <br /> Flow Information and Waste Type/Strength <br /> Estimated Design flow 600 Anticipated Waste strength ❑Hi Strength E]Domestic <br /> Any Non-Domestic Waste ❑Yes(class v) Q No <br /> Comments: <br /> Sewage ejector/grinder pump ❑Yes No <br /> Water softener ❑Yes ❑No <br /> Garbage Disposal ❑Yes No <br /> Daycare/In home business ❑Yes No <br /> Site Information <br /> Existing&proposed lot ❑Yes ❑No Well casing depth <br /> improvements located (see site map) <br /> Easements on lot located Q Yes ❑No Drainfield w/in 100'of ❑Yes 0 No <br /> (see site map) residential well <br /> Property lines determined ❑Yes ❑No Site w/in 200'of transient ❑Yes ❑No <br /> (see site map) noncommunity water supply(TNCWS) <br /> Req'd setbacks determined Q Yes ❑No Site w/in an inner wellhead ❑Yes ❑No <br /> (see site map) mgmt zone(CWS/NTNCWS) <br /> Utilities located&identified ❑Yes ❑No Buried water supply pipe ❑Yes ❑No <br /> (gopher state one call) w/in 50'of system <br /> Access for system maintenance ❑Yes ❑No Site located in Shoreland ❑Yes ❑No <br /> (shown on site map) (w/in 1000'of lake,300'of river) <br /> Soil treatment area protected ❑Yes ❑No Site map prepared with ❑Yes ❑No <br /> previous items included <br /> Construction related issues <br />