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DocuSign Envelope ID: D8AA32DD-94F0-4A26-ACCF-EFE01 D862864 <br />OmsTr riµ•{� Preliminary <br />GL4^"r MINNESOTA POLLUTION <br />T¢saTr.arir evaluation Worksheet m CONTROL AGENCY <br />Site within 200' of noncommunity transient well (YIN) Na <br />Yes, source: <br />Site within a drinking water supply management area (Y/N) No <br />Yes, source: <br />Site in Well Head Protection inner wellhead management zone (Y/N) No <br />Yes, source: <br />Buried water supply pipes within 50 ft of proposed system (Y/N) Na <br />B. Site located in a shoreland district/area? No <br />Yes, name: <br />Elevation of ordinary high water level: ft <br />Source: <br />Classification: Tank Setback:ft. <br />STA Setbk:ft. <br />C. Site located in a floodplain? No <br />Yes, Type (s), N/A <br />Floodplain designation/elevation (10 Year): NIA ft <br />Source: N/A <br />Floodplain designation/ elevation (100 Year): N/A ft <br />Source: N/A <br />D. Property Line Id / Source: ❑ Owner 0 Survey ❑ County GIS ❑ Plat Map ❑ Other: <br />E. ID distance of relevant setbacks on map: ❑ water ❑ Easements [] Well(s) <br />❑ Ruiiding(s) ❑� Property Lines ❑ OHWL ❑ Other: <br />4. Preliminary Soil Profile Information From Web Soil Survey (attach map ft description) <br />Map Units: LrB <br />Slope Range: % <br />List landforms: Hilly <br />Landform position(s): Back/ Side Slope <br />Parent materials: Till <br />Depth to Bedrock/ Restrictive Feature: i2 in Depth to Watertable: 1Z in <br />Septic Tank Absorption Field- At -grade: <br />Map Unit <br />Ratings Septic Tank Absorption Field- Mound: Not Limited <br />Septic Tank Absorption Field- Trench: <br />5. Local Government Unit Information <br />Name of LGU: City of Orono <br />LGU Contact: Brian Humpal <br />LGU-specific setbacks: <br />LGU-specific design requirements: <br />LGU-specific installation requirements: <br />Notes: <br />