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5(3). Site within a drinking water supply management area ❑ Yes ❑ No Source <br />5(4). Location of all existing and proposed buildings and Improvements on lot (see Site Evaluation map) <br />5(5)- Buried water supply pipes within 50 ft of proposed system ❑ Yes ❑ No <br />:. Location of all easements an lot (see Site Evaluation mdp) Source <br />D. Elevation of ordinary high water level (OWHL) - MN DNR (if ddJacent to parcel) <br />E. Floodplain designation and flood elevation .',�, - � ,.rx %, $', ;u s �,s:;,.t 3`.fi .. �Source <br />F. Determine property lines (see Site Evaluation map) ❑survey ❑,Plat Map ❑ Other <br />>ite located in a shoreland districtlar_eaa ❑ Yes [] No <br />S. Distance of setbacks .L'J Property Lines �g' ❑ OHWL ❑ Easements ❑ Water Supply Pipes ❑ WeR(s) <br />❑ Other Buildings <br />77, <br />H. Sol] Survey Information (from web soil survey) ❑ Map Ma Units on Parcel - t HN, <br />List <br />` <br />List landforms sFloUi e(a i g ` _ n ( Slope Range �� ,R'P <br />parent materials -check aU that apply Landscape Position (check all that apply) <br />❑Ti4 ❑Outwash ❑Loess ❑Bedrock ❑Alluvium ❑5ummit ❑Shoulder ❑Backslope ❑Footslope ❑Toeslope <br />❑ Colluvium ❑ LacusWne ❑ organic ❑ Cut/Fill <br />❑Depression ❑ Stream ❑Terrace [3 Manmade E] Plain <br />Minimum bedrock depth:Einches Minimum bedrock depth:Rflinches <br />Maximum bedrock depth:�ches Maximum bedrock depth finches <br />Septic Tank Absoprtlon Field- Trench (MN) I StittOWN, <br />Vap Unft <br />Ratings Septic Tank Absorption Field - At -grade (MN) <br />Septic Tank Absorption Field - Mound (MN) <br />Rlilt <br />'e.usm nu�vvrswn <br />ONSITE <br />Preliminary Evaluation Form SEWArE <br />TREATMENT ` <br />PRQGRAM <br />14. Preliminary Soil Profile Information (from web soil survey - map unit description & official series descriptions) <br />Unit <br />Unit <br />p Unit <br />Unit <br />Local Government Unit Information <br />NameofLGU <br />LGLI-specific setbacks <br />aY✓�.i :9 ,5--.v �r .: Maw -r �mn.'* 5 x r f�" l <br />LGU-specific design requirements <br />LGU-specific installation requirements <br />esu-.af <br />