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UNIVERSITY <br /> UF MINNESOTA OSTP Preliminary Evaluation Form �,�` <br /> ,,,Y,` <br /> 1.Cantectlnformallon °>>•'�5•'� <br /> Property O�nnerlCtlent:GabriN Jabbwr Clrent Phone Number: <br /> titaiGnQ Address 985 Tonkawa.Lan4 Lake.bt+55356 <br /> Site Address 4�10 Bi Island.Orono <br /> Parcell.D. To:���shiar� RNQ!? `N Sectton <br /> Date 7�2?�13 Tovmzhip name Lepal Desc or Lat:LonQ <br /> Evaluation for rysttm C/pe O i�.w Con:trucaon �Replacemenc paresl dimansiois <br /> 2. Flowlnformatlon <br /> I�nt ro n orma on <br /> Typ�lsl of use(all tlat Gpply� OO Readcnt�al ❑Commeroal ❑Other U:e�Sp�afy� <br /> No.of betlrooms'!ff appUcable� 4•xa5onal Unfi�isned space Iff`i �_— I <br /> No.of resiCents in Mme �Adults �Childron �T��naQan ❑oa�care <br /> :7ditln fl0'++mfiSurQfn�ntS ❑res ilt r.rs.att.N.li i.��Juiq.i ❑110 <br /> ❑Garbaoe Dcoo:al ❑�W aier:oftener� ❑Iron Fllter <br /> Watarvus.nqCe�ncei![htckofltlaf QP:hwa:her ❑;iun���Pump O[hlflSpCdf�1 <br /> ���y� 0 Lai E.'-&i W�uL/J,a urt i <br /> �H�qh Efhaenri Purnace <br /> ❑L�undry/L�rg�Tub on 2nd Fbar ❑H��•[Tul.� 'Clear v+ater source <br /> Water uz�concerns lcbeck a!!iha: Q Fauce VTmle� ❑I,�idopl:L�•ack ot Laurn.Yv/Day ❑Lone-Term PrrcnDoa�r•u� <br /> ���y) ❑In-Home Bu:me:: �No L�nc Screen ❑�1�.-�d:nri•Bm-.t�nal 5�-�.�p ❑Frequenc Entercain�ng ot Out-ol-Tov+n GwoC <br /> Any additimal arcent or future ozes on this parcal�specify) no <br /> Any non•sewaQe discharpn ta syseem IspeciJy 1 NO <br /> SexaQa oj�ctor or qnnd�r pump in noma ���% ���O <br /> I acknowledqe thQ abovo is complete and accunta �Cuent�s�sfgnature and darel <br /> Designer-d�terminad Flow Information <br /> A.Estimatad Dosign Flow(gallons per day) 330 <br /> Anticipatad•+�as[a strenqth values: ❑O Oomesuc ❑Mi��li;n�u�.�L BOD: •300 mq,� <br /> CBOD:�mQ'L ITSSI: �400 mpiL 0&G:�—�m41 <br /> 3. Preliminary Slte Informatlon <br /> 8�1).Water supply v✓ell(s)within 100 ft of a6sorptlon erea �yr. ❑�no <br /> Walllsl w�n lxated �Dn��.tOLeorvon�xi ❑G��untv Well Indr,.rn.�:c. ❑Periunal f�xnminn.anun NV!Unique W�II Id�: �—� <br /> Depth of well(s) NA f[ Well casing dep[h(s) NA —lft Source owner <br /> B(2).Slte within 200 ft of noncommunity transient suppty well �Y�= �i b Source owner <br /> B(3).Site within a drinking water supply management area ❑1'e: �t!o Source owner <br /> B(4).Locatian of all existinQ and proposed buildings and improvements on lot(see Si[e Evaluation map� <br /> B(5).Buried water supply pipes within 50 ft of proposed system ❑Y�c Q I b <br /> C.Location of all easements an lot(see Si[e Evoluatlon map� Source owner <br /> D.Elevatlon of ordinary high water level(OWHL)•MN DNR(ij adjacent to parcel) � <br /> E.Floodplein designetion and flood elevation Source owner <br /> F.Determine property lines(see Site Eva(ua[ion map) ❑O survei ❑Ptacnaap ❑ocher p�.��e� <br /> Site located in a shoreland district/zrea ❑Ye: 0 ib <br /> G.Distance of setbacks ❑G�i•�:��i N Un�s ❑OHW L ❑Ea:ement: ❑Y!ater Supply Pipe: ❑1V eLLr.� <br /> ❑Odie�&iddu,es <br /> H.Soil Survey Information(from web soil survey) �1hdP Map Uni[s on Parcel Lester Loam <br /> Lis[landforms moraines Slope Range 8-Jun <br /> Parent materials-check ail that appty Landscape Position(check all that opply) <br /> �T,,, n„ . , n,____ n q , ❑Allu�num ❑Summtt QQ Shouldei ❑Back:bpe ❑Foot:bpe ❑Toe:bpe <br /> ❑CdWvium ❑Lacu:tnne ❑OrQamc ❑iuVfiLL ❑Depre:;ion �Sveam ❑Terrace ❑%�+�made ❑Plam <br /> Minimum bedrock depth:�inches Minimum bedrak dep[h❑inches <br /> Maximum bedrock depth:�inches Maximum bedrock depth:❑inches <br /> Septic Tank Absorption Field-Trench(MN)Limited <br /> Map Unit <br /> Ratlngs Septic Tank Absorption Field-At-grade(MN)Limited <br /> Sep[ic Tank Abswp[ion Field-Mound(MN)Limited <br />