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. , 'UNIVBkSITY <br /> OF IVIINNESOTA Y��"������� <br /> OSTP Pretiminary Evaluation Form �� � �M� <br /> ��� <br /> 1.Con[act Information ��� 09 ZZ <br /> Property Owner/Client: Peter Eckerline Ctient Phone Number: <br /> Nailing Address 2555 Fox Street,Orono,MN 55391 Projed ID: <br /> ;ite nddres:Same <br /> ParceU.D. 4ll72344002 I Township#�� Rangelf Section <br /> Date 4/U/12 Township name Legal Desc or La[/Long <br /> Evaluaticn for system type ❑�lew Construc[ion �Replacement Parcel dimensions <br /> �1. Fiow Inforrt�ation <br /> Client-P:-oviAed information <br /> Tyrye(s)of use;a(([hot app(y) ��esidential ❑Commercial ❑Other Use(Spec.ify) <br /> Mo.of bedrooms'(iJ applicoble) 5 Unfinisbed space (f[Z) <br /> No.of resider�L in home �Adults �Children �Teenagers ❑Daymre <br /> Er.istinv flow measuremen[s ❑1'es(If Yes,attach readings) �ry� <br /> �Garbaqe Disposal ❑�Water Softene� ❑Iron Filter' <br /> Water-using devices(check ol!tha[ �p�shwasher ❑Sump Pump• Other(specijy) <br /> �ppty� ❑Large Bathtub/Jac�i � <br /> ❑High Efficiency Fumace' <br /> ❑Laundry/Large Tub on 2nd Floor ❑Hot Tub• 'Ctear water source <br /> W3ter use concems(check all that �`auceVToilet � <br /> ❑Multiple Loads of Laundry/Day ❑Long-Term Presaiptim Meds <br /> �P�y� ❑In-Home Business �No Lint Screen 0 Use of Anti-Bactenat Soap ❑Prequent En[ertaining of OuFof-Town Guests <br /> D.ny sdditional current or future uses on this parcel(specify) None <br /> IAny non-sewage discharges[o system (specify) None /� /, -� w /� <br /> ewage ejectcr or grinder pump in home ❑Yes �No <br /> ���r 4� <br /> II ackncw!ed3e Yhe above is canptete ar,d accurate lient s si no[ure and date) C` „y f ' �,(� <br /> y�li/Vi i�KI"�i <br /> lCesisner-determined Flow Informatior. <br /> A.Es[i;iiataci Design Flow(gallonz per dayj 750 <br /> �A��ticipated�aa�[e sVer�gtl�vatues: C�J pomestic ❑High Sae�gth BOD: mg/L <br /> CtSOL:��mg/L (TSS):�mg/L 0&G:��mg/L <br /> i. F'ieiiminar,Si[elnformation <br /> 1-=-�-_� <br /> �U(1y. !!at�r wr,ply weli(s)wi[hin 100 fi of absorption area �Yes ❑No <br /> �:leit�s)were(c-:ted ��rect Observation ❑Counry Well Index Maps ❑Personal Communication MN Unique WeU Id i1: � <br /> ��'�':����f w���(`� � >100 ft Welt casing dep[h(s)� 50 ft Source <br /> I <br /> �tmpervious Lay.:r �No ❑Yes if Yes,Define&Source: Required Se[back: 50 ft <br /> B(2).Site within 200 ft of noncommunity transient supply well ❑Yes ❑�No Sourte <br /> B(3}.Site wifhin a drin!cing water suppiy management area ❑Yes �No Source <br /> j P(��.Loca'i�n oi al!existing and propcsed buildings and improvements on tot(see Site Evoluation map j <br /> �':(5�.Buried w,.ter eupply pipes viithin 50 ft of proposed sys[em ❑Ves ❑�No <br /> �'.Lo�at�on of�II easements on lot(see Si[e Evaluation mop) Source Hen Cty GIS <br /> i <br /> iC:._fece'iun o(,rdinary higli wzter leval(OWHL)-MN DNR(if adjacent to parcel) �— � <br /> i. _ <br /> _.�:�:�dp:ain c`_,tgnatiusi and f;ood elrvati�n No Source <br /> i <br /> ,"..,.��-�r:��ne p,�uperty lines(see Site Evaluation map) �Survey ❑Plat Map �Other Survey$Hen Cty GIS <br /> .�i;c„red�n a shoreland distncUarea ❑y� ❑No <br /> � i�s+..uice of>et6acks ❑� :�roperty Lines ❑pHWL ❑v EasemenCs � <br /> ��� ❑Water Supply Pipes Q Well(s) <br /> ❑� Other Bui�ings <br /> .:�:.i!Scr:�ay i:dor��,ation(from web suil survey) U�MaP Map Units on Parcet L22Q Lester&L22D2 Lester <br /> Lisi:l.=.n4furms Craines Slope Range 8-14% <br /> _�.��rat_•�ia:;-che�k aU th.ot app(y Landscape Posi[ion�check all that opP�Y 1 <br /> . �':'.l j-..,::. .r..sP� C"�inass ❑&:.lrock ❑A:Wvium ❑Summit �Shoulder Q Badeslope ❑Foo[slope ❑Tceslope <br /> �''d'�.r;ii:�❑ ;J Lacus.rine 4'�Organic ❑Cu[/FiU ❑Depression ❑Stream ❑Termce ❑Manmade ❑Plain <br /> ,,,..�..un�ucdrxk depth:C�inches Minimum bedrock depth:❑inches <br /> �� Max:�num bedrock dep[h:�;nches Maximum bedrock depth:❑�nches <br /> 5eptic Tank Absorption Field-7rench(MN) <br /> ,�dap Untit <br /> i�s:,;;:; Septic Tank Absorp[ion Field-At-grade(.WJ)Restricted Percota[ion C�.42: Sloae C�.05 <br /> � Septic Tank Absorption Field-Mound(FAN) <br /> � �<�?— <br />