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Preliminary & Field Evaluation Form <br />..ScptkResource.com vers 12.4 <br />Design Flow 1200 Anticipated Waste strength <br />0 Hi Strength <br />Owner Information <br />Any Non -Domestic Waste <br />0 Yes(dass V) <br />O No <br />Date <br />7/18/2018 <br />Sec/Twp; Rng <br />Water softener <br />Parcel ID <br />0511723440011 <br />LUG (county, city, township) Scott County <br />O Yes <br />Property Owner: <br />Rudolph Residence <br />Owners address (if different) <br />O No <br />Property Address: <br />3280 Fox Street <br />residential well <br />City / State / Zip: <br />Orono, MN 55356 <br />O Yes <br />0 No <br />Design Flow 1200 Anticipated Waste strength <br />0 Hi Strength <br />2) Domeshc <br />Any Non -Domestic Waste <br />0 Yes(dass V) <br />O No <br />Sewage ejector/grinder pump <br />O Yes <br />0 No <br />Water softener <br />O Yes <br />C No <br />Garbage Disposal <br />O Yes <br />0 No <br />Daycare / In home business <br />0 Yes <br />O No <br />ting & proposed lot <br />0 Yes <br />0 No <br />Well casing depth <br />50'+ <br />'ovements located (see site map) <br />:mens on lot located <br />Q Yes <br />0 No <br />Drainfield w/in 100' of <br />0 Yes <br />O No <br />site map) <br />residential well <br />ierty lines determined <br />O Yes <br />0 No <br />Site who 200' of transient <br />0 Yes <br />O No <br />site map) <br />noncommunity water supply (TNCWS) <br />d setbacks determined <br />O Yes <br />0 No <br />Site who an inner wellhead <br />0 Yes <br />17 No <br />site map) <br />mgmt zone (C WS/NTNC WS) <br />ties located & identified <br />17 Yes <br />0 No <br />Buried water supply pipe <br />0 Yes <br />O No <br />ter state one call) <br />w/in 50' of system <br />ns for system maintenance <br />17 Yes <br />0 No <br />Site located in Shoreland <br />0 Yes <br />OO No <br />vn on site map) <br />(w/in 1000' of lake, 300' of river) <br />treatment area protected <br />O Yes <br />0 No <br />Site map prepared with <br />El Yes <br />0 No <br />previous items included <br />struction related issues <br />