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� Preliminary & Field Evaluation Form <br /> www.SepticResource.com vers 12.4 <br /> Owner Information <br /> Date 7/31/2015 Sec/Twp/Rng <br /> Parcel ID LUG(county,city,township) City <br /> Property Owner: Charles Krogness Owners address(if different) <br /> Property Address: 185 South Brown Road, Orono, MN <br /> City/State/Zip: Orono, MN <br /> Flow Information and Waste Ty e/ Strength <br /> Estimated Design flow 450 Anticipated Waste strength ❑ Hi Strength ❑� Domestic <br /> Any Non-Domestic Waste ❑Yes(class V) Q No <br /> Comments: <br /> Sewage ejector/grinder pump ❑ Yes � No <br /> Water softener Q Yes ❑ No <br /> Garbage Disposal ❑Yes � No <br /> Daycare/In home business ❑Yes 0 No <br /> Site Information <br /> Existing&proposed lot � Yes ❑ No Well casing depth <br /> improvements located (see site map) <br /> Easements on lot located ❑ Yes ❑� No Drainfield w/in 100'of ❑Yes 0 No <br /> (see site map) residential well <br /> Property lines determined ❑� Yes ❑ No Site w/in 200'of transient ❑Yes ❑� No <br /> (see site map) noncommuniry water supply(TNCWS) <br /> Req'd setbacks determined 0 Yes � No Site w/in an inner wellhead ❑Yes Q No <br /> (see site map) mgmt zone(CWS/NTNCWS) <br /> Utilities located&identified ❑� Yes ❑ No Buried water supply pipe ❑ Yes ❑� No <br /> (gopher state one call) w/in 50'of system <br /> Access for system maintenance ❑� Yes ❑No Site located in Shoreland ❑ Yes � No <br /> (shown on site map) (w/in 1000'of lake,300'of river) <br /> Soil treatment area protected ❑� Yes ❑ No Site map prepared with ❑� Yes ❑ No <br /> previous items included <br /> Construction related issues <br />