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�a <br />Client -Provided Information <br />Type(5) of use (aff that apply} ' IJ Residential ❑ Commercial <br />❑ Other Use (Specify)pp <br />No, of bedrooms` (if appllcoble) „' " °� " _ <br />c <br />No. of residents in home 0 Adults 13 Chi <br />Existing flow measurements ❑ Yes (If Yes, attach readings) <br />�rri <br />❑ Garbage Disposal <br />❑ Water Softener' ❑ Iron Filter' <br />i <br />❑Sump Pump` Other (specify) <br />apply) ❑ Large Bathtub/Jacuzzi <br />❑ High Efficiency Furnace' <br />❑ Laundry/Large Tub on 2nd Floor <br />❑ Hot Tub- ` Clear water source <br />Water use concerns (check all that ❑ Faucet/Toilet ❑ Multiple Loads of Laundry/Day ❑ Long -Term Prescription Meds <br />apply) ❑ In -Home Business ❑ No Lint Screen <br />❑ Use of Anti,Battenal Soap [3 Frequent Entertaining of Out -of -Town GI <br />Any additional current or future uses on thisarcel <br />P (specify) <br />Any non -sewage discharges to system (spedfy) <br />t <br />Sewage ejector or grinder pump in home ❑ Yes <br />No <br />I acknowledge the above is complete and accurate (Cllent(s) slynature and date)` <br />Designer-daterminad Flow Information <br />A. Estimated Design Flow (gallons per day) <br />Anticipated waste strength KJ Deme9Gc ❑ High Strength <br />Description: <br />tN <br />ohw <br />-ter <br />L <br />(A <br />A <br />w� <br />�pp <br />d' <br />G <br />At, % lll�lez rY C.6c/i <br />Preliminary Evaluation Form <br />ZA <br />ONSITE <br />SEWAGE <br />TREATMEN'j <br />PROGRAM <br />1. Contact Information <br />Property Owner/Client: f <br />' f <br />Client Phone Number: �� <br />Address <br />- <br />Parcel 1. D. <br />Township # Range # <br />r _' W Section- <br />Date MOM <br />- <br />Township name M1 , tt - Latitude/Longitude. <br />- <br />Evaluation for system type New Construction ❑ -31xisting Dwelling Parcel dimensions <br />2. Flow Information <br />Client -Provided Information <br />Type(5) of use (aff that apply} ' IJ Residential ❑ Commercial <br />❑ Other Use (Specify)pp <br />No, of bedrooms` (if appllcoble) „' " °� " _ <br />Unfinished space (ft') <br />No. of residents in home 0 Adults 13 Chi <br />El Teenagers 13 Daycare <br />Existing flow measurements ❑ Yes (If Yes, attach readings) <br />❑ Garbage Disposal <br />❑ Water Softener' ❑ Iron Filter' <br />Water -using devices (check all that ❑ Dishwasher <br />❑Sump Pump` Other (specify) <br />apply) ❑ Large Bathtub/Jacuzzi <br />❑ High Efficiency Furnace' <br />❑ Laundry/Large Tub on 2nd Floor <br />❑ Hot Tub- ` Clear water source <br />Water use concerns (check all that ❑ Faucet/Toilet ❑ Multiple Loads of Laundry/Day ❑ Long -Term Prescription Meds <br />apply) ❑ In -Home Business ❑ No Lint Screen <br />❑ Use of Anti,Battenal Soap [3 Frequent Entertaining of Out -of -Town GI <br />Any additional current or future uses on thisarcel <br />P (specify) <br />Any non -sewage discharges to system (spedfy) <br />t <br />Sewage ejector or grinder pump in home ❑ Yes <br />No <br />I acknowledge the above is complete and accurate (Cllent(s) slynature and date)` <br />Designer-daterminad Flow Information <br />A. Estimated Design Flow (gallons per day) <br />Anticipated waste strength KJ Deme9Gc ❑ High Strength <br />Description: <br />3. Preliminary site Information <br />B(1). Water supply well(s�thin 100 ft of absorption area [3 Yes No <br />Weli(s) were located Direct Observation ❑ County Weil Index Maps ❑ Personal Communication <br />Depth of well(s) rim' i ft Well casing depths)BlEgiffliffilm ft Source <br />5(2). Site within 200 ft of noncommunity transient supply well 0 Yes Q No Source <br />ests <br />