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' UNIVERSITY OSTP Preliminary Evaluation Form <br /> OF MINNESOTA <br /> 1.Contact Information v 03.19.15 <br /> Property Owner/Client:Tha^as��ePP Clien[Phone Number. <br /> Mailing Address 215 Hotlander Road,Orono,MN 55391 Project ID: � <br /> Si[e Address � Legat Descriptfon <br /> ParcHID: Z5��8234400�3 . Wtitude Longttude <br /> Evaluation for system type ❑New Coretrumon �ReWxmKnc Date �Ptember 8,2016 � <br /> 2. Flow Information <br /> ent-Provi In ormation <br /> TYpe(s)of use(ail that�ply) ��'� ��^"�� 0�'(�'F/) <br /> No.of bedrooms'(iJ�plicoble) 5 Unfinished space (ft2) <br /> No.of residents in home ❑2 Adults �Chiidren �Teenagers <br /> Existing flow measurements OYCS(It Yes,aG�h r�lnp5) Ot�o <br /> OGa�bage Dkposal QQ WaOer Softma* Dlron F� <br /> Water-using devices(check all that �'��""�'g ��"'v�v' Other(specify) -� <br /> aPP�Y) �Large eatliwNJac�� �+Fe9h ERlcimc�Fumxe* <br /> Qlaundry/I.arge Tub on 2nd fbor Otae ruw •Clear water source <br /> water use concems fcneck o!!thot pFa,�eqratec t.eal¢ ❑Mumde�oads of taunay/oay O�ony-ram vraaipoon r�fees puse a nm�-eacteda�soap <br /> �P�Y) QIMiame Business ❑�No LiM Saeen ❑FrequeM En[ermining of Outof-Town Guests <br /> Any additional current or future uses on this parcel(specijy) NO <br /> My non-sewage discharges[o sys[em (speci/y) NO <br /> Sewage ejector or grinder pump in hame? ❑Y� �� <br /> I acknowledge the above is complete and acarate � (Client(s)signature ond date) <br /> Destgner-determined Fiow Informatfon <br /> A.Estlmated Design Flow(gallons per day) 750 <br /> Anticipated waste strength values: ❑��"�Strengm ❑Hph Strcqm BOD: mg/� <br /> CBOD:�mg/L C�S)��mg�L 08G:�mg/L <br /> 3. Preliminary Site InformaHon <br /> B(1).Water supply weil(s)within 100 ft of absarptlon area �ves �wo <br /> Well(s)were located �oirect ohservanon OCounry weu Ndac Maps Ope,wnal Cmmun�aon MN Unique Well Id/t: � <br /> Depth of well(s) ft Well casing depth(s) ft Source� <br /> Impervious Layer ❑� �g If Yes,Define&Source: Required Setback: �ft <br /> B(2).Site within 200 k of noncommuniry transient supply well �Yg �° Source� <br /> B(3).Site within a drinking water supply management area �Y� Owo Source� <br /> B(4).Location of all existing and propoud buildings and improvements on lot(see Site Evaluatton map) <br /> B(5).Buried water supply pipes within 50 ft of proposed system ❑Y�s QQ No <br /> C.Location of all easements on lot(see Site Evaluation map) Source County GIS <br /> D.Elevatlon of ordinary hlgh water levet(OWHL)-MN DNR(if adjacent to parcel) n/a <br /> E.Floodptain destgnation and flood elevatlon n/a Source owner <br /> P.Determine property lines(see Site Evaluation map) �Survey ❑Plat Map Q�,�; <br /> Site located in a shorHand district/area �Yg ��'1O <br /> G.Distance of sMbacks �h0�'�'"� ��� �W��"�N%� <br /> QOtl�erBuiNings ❑EaSetnents ❑Well(s) <br />