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� Preliminary & Field Evaluation Form <br /> ww�w.SepticResource.com vers 12.4 <br /> Owner Information <br /> Date 3/22/2016 Sec/Twp/Rng <br /> Parcel [D 3111823420012 LUG(county,city,township) Hennepin County <br /> Property Owner: !'!:�` � :✓�; Owners address(if different) <br /> Property Address: 4220 Chippewa Lane <br /> City/State/Zip: Orono, MN 55359 <br /> Flow Information and Waste Type/Strength <br /> Estimated Design flow 750 Anticipated Waste strength ❑ Hi 5trength ,�' Domestic <br /> Any Non-Domestic Waste ❑ Yes(class V),e'No <br /> Comments: �—,� <br /> Sewage ejector/grinder pump ❑ Yes I� ��o <br /> #Water Softener should be re-routed <br /> so it does not drain into septic system � Water softener �Yes � No <br /> Water softener can be routed to drain into footing tile and <br /> surface outl Garbage Disposal ❑ Yes „�No <br /> Daycare/In home business ❑ Yes �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 � No <br /> (see site map) residential well <br /> Property lines detennined .�Yes ❑ No Site w/in 200'of transient ❑ Yes �` No <br /> (see site map) noncommunity water supply(TNCWS) <br /> Req'd setbacks determined Yes ❑ No Site w/in an inner wellhead ❑ Yes � No <br /> (see site map) mgmt zone(CWS/NTNCWS) <br /> Utilities located& identified ❑ Yes � No Buried water supply pipe ❑ Yes r/j No <br /> (gopher state one call) � w/in 50'of system l <br /> Access for system maintenance �Yes � No Site located in Shoreland ❑ Yes �j No <br /> (shown on site map) (w/in 1000'of lake,300'of river) T <br /> Soil treatment area protected Yes ❑ No Site map prepared with ,�s ❑ No <br /> previous items included <br /> Construction related issues <br />