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Preliminary & Field Evaluation Form <br /> www.SepticResource.com vers 12.4 <br /> Owner Information <br /> Date 12/12/2017 Sec/Twp/Rng <br /> Parcel ID 0611723220029 LUG(county,city,township) Hennepin County <br /> Property Owner: M and M Construction Owners address(if different) <br /> Property Address: 125 Bayside Trail, Orono, MN 55359 <br /> City/State/Zip: <br /> Flow Information and Waste Type / Strength <br /> Estimated Design flow 750 Anticipated Waste strength ❑ Hi Strength E] Domestic <br /> Any Non-Domestic Waste ❑ Yes(class V) No <br /> Comments: <br /> Sewage ejector/grinder pump ❑ Yes n No <br /> Water softener El Yes ❑ No <br /> Garbage Disposal ❑ Yes No <br /> Daycare/In home business ❑ Yes 0 No <br /> Site Information <br /> Existing&proposed lot El Yes ❑ No Well casing depth <br /> improvements located (see site map) <br /> Easements on lot located ❑E Yes ❑ No Drainfield w/in 100'of ❑E Yes ❑ No <br /> (see site map) residential well <br /> Property lines determined ❑ Yes ❑ No Site w/in 200'of transient ❑ Yes ❑ No <br /> (see site map) noncommunity water supply(TNCWS) <br /> Req'd setbacks determined Ri Yes ❑ No Site w/in an inner wellhead ❑ Yes 0 No <br /> (see site map) mgmt zone(CWS/NTNCWS) <br /> Utilities located&identified ❑ Yes 0 No Buried water supply pipe ❑ Yes Ri No <br /> (gopher state one call) w/in 50'of system <br /> Access for system maintenance C Yes ❑ No Site located in Shoreland ❑ Yes 0 No <br /> (shown on site map) (w/in 1000'of lake,300'of river) <br /> Soil treatment area protected 0 Yes ❑ No Site map prepared with Ri Yes ❑ No <br /> previous items included <br /> Construction related issues <br />