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UNIVERSITY OSTP Preliminary Evaluation Form <br /> OF MINNESOTA <br /> 1.ConWct InformaHon v 05.31.13 <br /> Property OwneNClient: Mark Larson CUent Phone Number: �63-479•5268 <br /> AAailing Address 366 North Artn Lane,Orono.MN Project ID: <br /> Site Address Same Legal DescripHon <br /> ParcellD: Latltude Longitude <br /> Evaluallon for system type ❑��^ ���f1B"t Date SeP����.2013 <br /> 2. Flow Information <br /> C ient-Pr d In orma on <br /> Type(s)of use(all that app/y) �'Res�de"na� ❑c°"n'e"�a� �`(�ry) <br /> No.of bedrooms'(if appUcable) 3 Unfinished space (ft�) <br /> No.of residents in home �Adults �Children �Teenagers ❑�re <br /> Existing flow meawrementr �'es(�f Yg,aaach reaangs) �rio <br /> QGarbage Dkposal +❑WaOer SofOena' ❑Iron FBte• <br /> Water-using devices(check all that ��'W��` �sump aump� Other(speci(y� <br /> aPP�Y) �anx eaMn,b/�x�i QHlgh Effkkncy Furrete' <br /> ❑Laundry/Large Tub on 2nd Hoor �Ma T�b' •Clear water source <br /> Water use concems(check all that �FauceQ/iolkt LeeAs ❑MuRlpk Loads of laundry/Day QLong-Term Prescrlptlon MedS ❑Use W A�-Bat[erlal Soap <br /> npPly) ❑IrrHome Buskrss QNo LIM Streen QFrequeM Enletalning of Ou[oFTown Guesls <br /> Any additlonal current or future uses on this parcel(speciJy) <br /> Any non•sewage discharges W system (spedfy) <br /> Sewage eJector or grinder pump in homeT Q''g �No <br /> I acknowledge the above is canplete and accurote (Client(s)signature and date) <br /> Designardetermined Flow Information <br /> A.Erttmated Design Flow(gallons per day) 450 <br /> Antldpated waste strength vaWes: �D0R1�S°p"gn' ❑H�gh strcigth BOD: mg/L <br /> CBOD:�mg/L (T55):�mg/L 0&G:�mg/L <br /> 3. PreUmtnary Site Informatlon <br /> B(1).Water supply well(s)within 100 ft of abwrption area ❑Y"S '❑N° <br /> Well(s)were located ❑�a��^'e�^ ��H�"/ell lndac Maps ❑versona�communkation AAN Unique Well Id#: � <br /> Depth of well(s) 100'+ ft Well casing depth(s) N/A ft Source� <br /> Impervious Layer �� ❑�'g If Yes,Define&Source: Required Setback: �ft <br /> B(2).Ske wlthin 200 ft of noncommunity Vansient supply well �g �° Source MN Dept.Health <br /> B(3).Site wltMn a drinMng water wpply management area ❑�P5 �'No Source MN Dept Health <br /> B(4).Location of all euisting and propased buildings and improvements an lot(see Site Evaluation map) <br /> B(5►.Buried water supply pipes wlthln 50 ft of proposad system ❑Yg ❑�No <br /> C.Location of all easements on lot(see Site E�roluatlon map) Source <br /> D.Elevation of ordinary high water level(OWHL)-MN DNR(if adjacmt to parcel) <br /> E.Floodplain designation and flood elevallon Source � <br /> F.Datarmtne property lines(see S�te Evaluatlon map) ❑S�^'n' ❑wa�Map �r <br /> Site located in a shoreland disWd/area ❑No �'es,name: <br /> G.Distance of sMbacks �ProD�Y�� ❑�� �'Nater Supply Pipes <br /> ❑otha Bulldings QEesemmis ❑WdKs) <br />