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' . ' Vx�vuinypvWvvemin <br /> atd517[ <br /> Preliminary Evaluation Form �F4�A�t: <br /> �REdYMENT <br /> F'ROCRpA1 <br /> 1.Contact Informadon <br /> Property Owner/Client: Qient Phone Number: <br /> Address 2650 FoxStrcet,Orono,'MN 55391 <br /> Parcel I.D. 411723�410003' Township# Range N ` W Section <br /> Date 8/15I10 Township name ' ;`: LaNtude/Longitude <br /> Eva(uatton for system rype New Constructfon 0 �Fxisting Dwelting Parcel dimensions ? <br /> .�`� �„�� <br /> 2. Flow Informatfon <br /> Client-Provided Informatlon / <br /> Type(s)of use(a(1 thvt cpply) �❑Residential ❑Commerdal ❑Other Use(Speciry) ��sr,� ,:; <br /> �,_�,_ 7..:� <br /> No,of bedrooms'(tf oppticabte) ,,:�3r�1���;�.��,� Unfinished space (ft2) <br /> No.of residents in home Adults ❑Children ❑Teenagers �Daycare <br /> Existing flow measurements ❑Yes(If Yes,attach readtngs) � <br /> ❑Garbaqe Dfsposal ❑Water Softener' ❑Iron Filtei' <br /> Water-using devices(check all that ❑Dishwasher ❑Sump Pump• Other(specify}��;��R�C�rY t�1, '> <br /> aPP�Y) <br /> ❑Large Bathtub/Jacuai ❑High Efficiency Fumace' <br /> ❑Laundry/Large Tub on 2nd Floor ❑Hot Tub' 'Clear water source <br /> Water use concems(check o/l thot ❑Faucet/Toilet ❑Multiple Loads of Laundry/Day ❑Long-Tertn Prescriptton Meds <br /> �P�� ❑In-Home Busfness <br /> ❑No Lint Screen ❑lhe of Anti-Baderial Soap ❑Frequent Entertaining of Out-of-Town Guests <br /> Any additlonal current or future uses on this parcel(speclfy) <br /> Any non-sewage discharges to system (specify) <br /> Sewage eJector or grinder pump in home ��Yes No <br /> I acknowledge the above is complete and accurete (Client(s)signature md date) �Y��a�;��+`�� ��;k�"�y� ,�r�,�s�'�=�.� r�+�r��,��,� <br /> Designer-determined Flow information <br /> A. Estimated DestQn Flow(gallons per day) "",=ay�"� '�,h �� <br /> ' ��Y�n�s .a,' <br /> Anticipated waste strength �Domestic ❑High Strength pescription � '` v,���`��l �e �,, �: <br /> 3. Prel(minary Site Information <br /> B(1).Water supply we(1�s�thin 100 ft of absorptfon area ❑Yes No <br /> Well(s)were located Direct Observation ❑Gounty We4 Index Maps ❑Personat Communication <br /> Depth of welt(s) +�€�'�`�����.+". �'� ' _,��k ft Well casing depth(s)�r °`��; ,�,�����`���''���;`;�:"ft Source <br /> B(2).Site within 200 ft of noncommunity transtent suppty well ❑Yes ❑No Source <br /> B(3).Site within a drinkinQ water supply management area ❑Yes ❑No Source <br /> B(4). Location of atl existing and proposed buiidings and improvements on lot(see Site Evoluotion map) � <br /> B(5).Burled water supply pipes within 50 ft of proposed system ❑Yes ❑No <br /> C. Locallon of all easemenb on lot(see Site Eva[uotlon map) Source REALTOR ° 'b� ,`�.h �'. <br /> D. Elevatlon of ordlnary high water level(OWHL)-MN DNR(if adJac�nt to parc�l) <br /> E. Floodplaln designatfon and flood elevation �,,c����, �;x,�4 yw,��w����b��'��.,,:�,r.;. Source <br /> F. Determine property Ilnes(see Slce Evoluotfon mc�) ❑Survey ❑Plat Map ❑Other n ''� ��;� "'`' <br /> ,a:� '�t �� <br /> Site located in a shoreland district/ar,�ea/ ❑Yes ❑No <br /> G, pistance of setbacks .�Property Lines lb` ❑OHWI ❑Easements ❑Water Supply Pipes ❑WeU(s) <br /> ❑Other Buildings <br /> H.Sofl Survey IMormatfon(from�wb soif survey) ❑Ma b ? � ,r +r.,r <br /> P Map Units on Parcel Angus•Kilkenny ;' ,��"^'��� +� ,�����,� <br /> List landforms �F�� (d���+��?y"�� �' ; <br /> � :r �s;.K. �. Slope Range <br /> Parent matetials-check oll that appty Landscape Position (check a(l that apply) <br /> ❑TiU ❑Outwash []Lcess ❑Bedrock []AUwium <br /> ❑Summit ❑Shoulder ❑Backslope ❑Footslope ❑Toeslope <br /> ❑CoUuvium O lacustrtne ❑Organic ❑Cut/FiU <br /> ❑Depresston ❑Stream ❑Terrace ❑Manmade ❑Plain <br /> Minimum bedrock de th:�inches `" <br /> p Mi�imum bedrock depth:;,a�'�inches <br /> Maximum bedrock depth:, '�ches Maximum bedrock depth::��inches <br /> Septic Tank Absoprtion Field•Trench (MN) Lfrimited <br /> Map Unit <br /> Ratings Septic Tank Absorption Field•At-grede(MN� Lfmiteci <br /> Septic Tank AbsorpNon Fietd�Mound (MN) lfmlted <br />