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DocuSign Envelope ID: D8AA32DD-94F0-4A26-ACCF-EFE01 D862864 <br />Preliminary <br />(1:,r.,T, kt� MINNESOTA POLLUTION <br />St rrr r.r M <br />T;rin•rr.,,,,r Evaluation Worksheet CONTROL AGENCY <br />1. Contact information v 04.01.2021 <br />Property Owner/Client: Regency Homes Date Completed: 1/25/2022 <br />Site Address: 2925 Deer Run Trail, Orono Project ID: <br />Email: Phone: <br />Mailing Address: Alt Phone: <br />Legal Description: <br />Parcel ID: SEC: TWP: F77�] RNG: <br />2. Flow and General System Information <br />A. Client -Provided Information <br />Project Type: 21 New Construction ❑ Replacement ❑ Expansion ❑ Repair <br />Project Use: ❑� Residential [❑ Other Establishment: <br />Residential use: # Bedrooms: Dwelling Sq.ft.:Unfinished Sq. Ft.;� <br /># Adults: # Children: # Teenagers: <br />In-home business (Y/N): If yes, describe: <br />❑ Garbage Disposal/Grinder Dishwasher ❑ Hot Tub - <br />Water -using devices: ❑ Sewage pump in basement ❑ Water Softener* ❑ sump Pump* <br />(check all that apply) Q Large Bathtub >40 gallons ❑ Iron Filter* ❑ Self-cleaning Humidifier* <br />❑✓ Clothes Washing Machine ❑✓ High Eff. Furnace* ❑ Other: <br />" Clear Water source - should not go into system <br />Additional current or future uses; <br />Anticipated non-domestic waste; <br />The above is complete ft accurate: <br />Client signature & date <br />B. Designer -determined flow Information Attach additional information as necessary. <br />Design Flow: 750 GPD Anticipated Waste Type: Residential <br />BOD: <170 mg/L TSS EiKAmg/L Oil It Grease X25 mg/L <br />3. Preliminary Site Information <br />A. Water <br />Supply Wells <br />Well Depth <br />Casing <br />Confining <br />STA <br /># <br />Description <br />Mn. ID# <br />(ft.) <br />Depth (ft.) <br />Layer <br />Setback <br />Source <br />1 <br />2 <br />3 <br />4 <br />Additional Well Information: <br />