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L1V f V FRSITl' �J <br /> OF M[NNE;SOTA OSTP Preliminary Evaluation Form <br /> t.Corrtact informatian v 11.05.31 <br /> Property Owner2iienC Taiy Wnd Client Phone Number: ,'Z, –�;y I–� )- <br /> MaHing Address 360 North Arm Road Orono MN. <br /> Site Address Same <br /> Parcel I.D. Tamship#� Range# —�W Section <br /> Date 9/Z3/11 Township name Orono Legal Desc orLat/Long <br /> Evaluation for system type New Corrstruction �RePtaoemem Parcel dimertsions <br /> L Flow Mfomiation <br /> i-R'ovided ortn�ion <br /> Type(s)of use(o(!that�p(y) "Residential Canmerdal �Other lke(SpedfY) <br /> No.of bedrooms'(if applicoble) 5# llnfinished space (ft2) <br /> No.of resfdents in home ❑2 Adults �Children ❑Teenagers Daycare <br /> Existing flow measurements Yes(if Yes,atiach readings) �No <br /> Garbaae Disoosat �water Softenef Uon Rlter <br /> Water-us6ig de.wices(check cll that ..Dishwasher Sunp PeanP Other(spedlY 1 <br /> ��y) Wrge BathG�/Jaatr� High Efficiency Fumace' <br /> W�aidry/Large T�ai 2nd fbor }��T�• 'Ctear water source <br /> Water use crncerns(d�eck alt that FaixetlToilet Multiple Loads of Laundry/Day La�g-Tertn Presaiptlon Meds <br /> °�ty� In•Hame&ainess No LirK Saeen Use of Anti-Bacterial Soap Frequa�t En�irring of Ou[-of-Tov�s�Guests <br /> My additional current or future uses on this P��(�pfY 1 <br /> /uiY�mn-sewaSe discharges to system (spedJ!l) <br /> Sewage ejector or grinder qxenp in home Yes �No <br /> 1 aclmowledge the above fs oomplete and accurate {Clierit{s)st�ae md�e) <br /> Designer-determined Ffow IMormation <br /> A.Estimated Design Flow(gatlons per day) �'� <br /> Mdcipated waste stren8th vatues: �Danestic High StrengM �� mg/L <br /> CBOD:�mg/L (TS5).C�m3/L 08G:�ms3/L <br /> 3. PreBminary Site Irtformation <br /> B(1).Water suppy wett(s)wfl�hin 100 ft of absorytton area �Yg � <br /> Wetl(s)were tonted �Direct Observadon Canty WeU Midex Maps Personal Cortunurimtiai AAN Unique WeU!d#: � <br /> Depth of welt(s) ? ft Well casing depth fs) ? ft Source <br /> B(2).Stte within 200 ft of noncommurfity transfent wpply well Yes �No Source <br /> B(3).Slte wlthin a ctrinking water wpply nwnagement area Yes �No Source <br /> B(4).Locatbn of a!!eztst4ig�d proposed buiWings and imp►wements on lot(see Site Evaluatian mt�) <br /> B(5).Buried water sWP�Y PiD�within 50 ft of proposed system Yes ✓No <br /> C.Lxation of alt easements on 1�(see Site Evnluatia�m�) Source None <br /> D.Ekwation of ordinary high water level(OWHL)-MN DNR(if odjacart to parce() None <br /> E.Floodplain designation and flood elevation None Source <br /> F.Determine proparty rines(see Sl te Ewaluation m�) �Swvey Plat Map Other <br /> Site looted in a shoreland district/area y� � <br /> G.Distance of setbsdcs �PropeRy L9nes OHWI Easemerrts Water Supply Pipes �WeU(s) <br /> OUter&iii�tings <br /> H.Soil Survry Ireformation(frarn web soi(wrvey) MaP Map Ur»u on Parcel <br /> List landfortns 5[ope Range <br /> Parent materials-�heck af(ihat c�lY Landscape Positlon(check alt that c�ly) <br /> .�TiLL Outwash Loess Bedrock Atluvitan Summit v Shoutd� Badcsbpe Footslope 7aesbpe <br /> Col6rvi�an Lacustrine Organic Lut/FU D�ression Stream Terrace Manmade Plain <br /> Minimurn bedrodc depth:❑0 inches Minimum bedrock depth:❑0 inches <br /> AAaximum bedrodc depM:❑0 inches Maximum bedrodc depth:❑0 inches <br /> Septic 7ank Absorption Fieid-Trenth(AAP!) <br /> Map Unit <br /> ��S Septic Tank Absorption Field-At-grade(MN) <br /> Septic Tank Absorptfrn Fietd-AAound(MN)10"x 63 Rodc Bed 17"sand 2250Trash tank 1300 Pump Tank <br />