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' Uh'IVERSITY <br /> OF IVIINNESOTA OSTP Preliminary Evaluation Form <br /> � <br /> 1.ConLactlnformallon v 11.05.31 <br /> PropeRy OwnsrKliant: Uient Phone Number: <br /> MaillnQ Addrcss <br /> Site Addrcss�360 Chippewa Lane,Orom,MN 55359 <br /> Parcel f.0. 71•118•3•�2•0015 Townshlp g� RanBe p W Sectim <br /> Dste 70/8/11 Township neme Legal Desc or Lai/Long <br /> Evaluatlon for system type ❑��onsvuttlon m Repinceme�t parcel dimensions <br /> 2. Plowlnformatlon <br /> CtienaProvided 1 ormatlon <br /> �ype(s)oi use tatt rnoc appfy) �R�sldentlsl O Commartlal ❑oU,er use lspearyl <br /> No.oi bedrooms'(1f apyllcaWe) � 5 � Unflrdshed space (ft=� <br /> No,of resldenK In Mme n2 Adults �5 Ghildren ❑Teenagers 0 Daycare <br /> Extsting flow measuremenb ❑Yes(tf Yes,actach rcadtngs) ❑ryo <br /> ❑GarDaqe Disowal �Water Softensr' ❑Iron Flket' <br /> Water•uslny devices(check afl tlwt �Dlshvsstxr ❑Sump Pump• Other(sptclfy) <br /> �Y� m txQe Bathtub/Jacuai <br /> �Hlgh£ttidency Furt�ece' <br /> ❑teundry/Large 7ub on 2nd Floor �Hot Tub' ����water source <br /> Water use concerm(check alf that �Fauoet/Tolkt ❑MulUple Loads of Laundry/Oey ❑Long•7ertn PrestAptlon Meds <br /> °�ry) ❑In-Home Bualneas �Mp Ltnt Saean ❑Use of Antl-8actertal Soap ❑Frequent Entertalning of Out•o/•Twm Gueses <br /> My eddttianal currcnt or future usa on this parcd(speclJy) no <br /> My nomsewaQe dixharges to system (rpeclJy) NO <br /> Sewege ejectw or gr4rMer pump in home ❑Yes CY]No <br /> I acknowledge the above Is complete and aaurate (t(fmt(s)sfgnotun anQ dote) <br /> Deslyner-d�brmined Flow Infornatlon <br /> A.Estlmaqd Ds�l{rt flow(pllom per day? 7� <br /> Mtfcipated wute strcngth values: �ppmastic ❑Hlgh SVenqth �D:� �'� mg/L <br /> CBOA:�mQ/L (T55): "� mg/l 0&G:�mq/L <br /> 7. ProliminuySlalnfwmatlon <br /> B(t).Waur wpply w�lf(s)w1fl�in 100 ft of absorpdon ana ❑Y� [$ryo <br /> Well(s}were lotated ����8��QrvB��a^ ❑County WeU 3�dcx Meps ❑Personal Comm�nfuiton 1M1 Unique Well Id 11: � <br /> Depth ot well�:) Na ft wefl casinq depth{s)� NA �f[ Source ovrtxr <br /> 8(2).SiG within 206 fL of noncommunity transl�M supyly w�ll �Yes �No 5W�re p�.��� <br /> B(3).Sfb within a dNnklna watar suppry m�na;sm�nt ar�a �I Yes �No Sourcp owner <br /> B(1).iocallon of al[ezhtln�aed proposed bulldinjs anA improwm�nts on bt(ue Slte Ewluotlon rtwp) <br /> B(5).Burfed watar suppEy plpss withln 50 R ot proposad sysqm ❑Yes �No <br /> C.LouHon af aU aawm�nts on(ot(set Slte fvaluat/on rr�) Source owner <br /> D.Elev�tbn of ordin�ry hl�f water lawl(OWFiL)-MN DNR(ij adjacent to parc�f) �_-� <br /> E.Floodplaln desl`natlon and Hood�levadon 5�r� �� <br /> F.D�brmins propsrty Hnet(sse S/tt EwluoHon mcp) �SurveY �Vlet Map Q Other pN,�H <br /> Site located In a shoreland dlsMct/area [j y� m� <br /> G.DlsLna of setbacks ❑Woperty Ling ❑OHWL ❑Easements ❑Water Supply Plpes [']WeU�s) <br /> ❑Other Bulldings <br /> H.SoIlSurv�y Inlormadon(from w�b uif survey) �MaD Mep Untts on Parcel Lester Kilkenrry <br /> Llst landforms morolna SWpe Range�- 8•Jun <br /> Perent materials•check a!1 that apply Landscape Potitfon(chKk al!thct opp(y) <br /> p r�u p ouc�sn ❑�oess p eearock p auwsum ❑Summit �sna,mo� ❑eadcsbpe ❑Fooa�ooe t7 roesu�e <br /> ❑Cotlwlum ❑LaasMne ❑OrgaMc ❑Cut/flQ <br /> j]Depresslon []Stream ❑7erreca []Menmsde Q Pleln <br /> AGnimum bedrock depth:�inches Minimum bedrock depth:ainches <br /> Maxlmum bedrock depth:ainches Meximum bedrak depth:❑inc�a <br /> Map Unit �P��c Tank Absorption Fleld-TrencFi(MN}Umited <br /> Ratings Septic Tenk Absorptlon Fleld•At•grade(MN)Limtted <br /> Septic Tank Absorptfon Feld•Mound�MN)Limited <br />