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� �Niv�itSITI' pSTF Prelirnina Evaluation Forrn <br /> � v�h�iir���so�r� ry - <br /> 9.Cantad i+�tormatbo v 12.OB.ti6 <br /> Property OwnarlGlent Steva Mdea'wn/Denall Hames Cltent Phone Number:�^ � <br /> Mailin6�►� Projeci ID: i � <br /> Site Address 517 Femdite Road f�th,Orora,NW 5539t <br /> ParcellD: 3b•118-23-14n007 Latituder � Longitutle� ����� <br /> fvatuation Ea system type O New caaauumn+ ��a [3ate�_Marth 19,2015 <br /> 2. Ftow 11�ormeUon <br /> -p h <br /> 7ype{s)af use{at4 that q�ply) �ae�u�a� C��+e+,crc� �Otl,er{sv�v) <br /> No.of bcdroans`f�f��le) � 4 Unffn�hed�ace (ft�) Accamted ta. � <br /> No.oi residenis in home �2 Adutts �CMldrm ❑7eenagers �� <br /> E�ti�tlow mcea�suremcmts Ll res tu rrs,err�reeemvs) C�7 xo <br /> O c�e o�osar [�ro�r sd�a� ��n r�+ <br /> Water-usfsu�,'devices(dteck atl tl�ar �as�west� ❑sunw�nv' Otlaec'{spetlf!') �� 1 <br /> ap?�9) �tar�e e�itt+n�+/� �H�Efi�o�.v wmea` <br /> C7 ua�rlta�oe r�a�z��ar ❑rka Twr -[tear vrater�ce <br /> Water use ca�ccems(check al!that Q�ac�exl�aet�w� �wu�pk a�ce teu�rl�r ❑�o-re�m vr�apew�rxxis �use a nm3-Bnceeriai smp <br /> �nh/ O m•tiome susm�ess I�wo um saan ��n Enrrarnwinp ora,ea�own c�ta <br /> Any additiar�al currmt a fuwre uses a�khfs parcet{speciJy y No <br /> My non-Sevrage discharges to sysGem (speclfy) NO <br /> Sewage ejector a grinder punp in hmie? O va 0 no <br /> I ackrwnvfedge the above is complete and accurMe (Ctient(s/signawre mid�ote) !� <br /> !)ea�ner-detemtiined Ftow i�rformation <br /> A.Esdmated Oes1Qn Fbw(gaibns per day) C�� <br /> Antkipated waste sVength vat�res: C�oomcalc�.eng[i� ❑wkjn,trma�+ �� mg/L <br /> CBOD:C�mg/L (T5S):��mg/l 0&G:��m811. <br /> 3. Pretlminaty Sfte IMormaLion <br /> Bt t).water suppty w�eU(s)wit�10o tc ot,bsorptsan m�ea �v� C1 No <br /> Well{s)were I�ated ���' ❑�"'�1'weJl LMex Maps ❑Pnsa�el C�mi��a� MP!Ib+ique Wetl td Jk C^_� <br /> Oepth of weit{sy >100 ft WNt casing Ae�th(s)� _ 50 �it Souroe� <br /> �m�xrvlous tayer OO rm C7 Yes K Yes�Define&Stwrce: Requfred Setbadr �ft <br /> 6(2).sate with�n t0o ti of mncommanEry transle�wppFy weti C�va D ao 5��e�^� <br /> 9(3).Site within a�b+kfr�g water wppfy manasement area C1'ves ❑No ��� <br /> B(4).lacatlm�ot aii existlng and proposed bulMf�and im{xovemeMs on bt(see Sftr£vnluetlory�p I <br /> 9{5).Buried w�wPP�Y P�wtUdn 80 ft of proposmd syst�eq ❑Yns �No <br /> t.Lacatton of ntl aasements on bt(see 51 te EVMuctbn mcp} So�uce Simey <br /> D.Elevatlon of ordtnary h1�+water le�vel(OW►IL)•MN DNR tif adjacent M pprcel) �� �� <br /> E.FloodplaM destg�attan mid tbvd eleratton ��� �Sa�rce �� <br /> F.Determine property ttnea(see Sl te Evatuotlon mop) �5wvcr G'pret n,ip ❑otner: <br /> Site taated in a shoreiand drsLrict/area ❑Y� -�'. � <br /> c.o�tance oi setbacks ��arer� LI cx+m O we�suvvk p� <br /> [7 on�eu� [��s El wa�ts� <br />