Water Quality Onsite Program
Onsite Program 165 E. Seventh Ave., Suite 100 Eugene, OR 97401 Phone: 541-686-7838 800-844-8467 Fax: 541-686-7551 Contact: Randy Trox www.oregon.gov/DEQ DEQ is a leader in restoring, maintaining and enhancing the quality of Oregon’s air, land and water.
Onsite Technical Review Committee Meeting #1
Jan 9, 2019 Location Oregon Dept. of Fish and Wildlife, Classroom 4034 Fairview Industrial Drive SE, Salem List of attendees
• Trent Clinkscales • Lisette Hamer-Richardson • Josh Graves • Todd Cleveland • Connie Schrandt • Brittany May • Brian Rabe • Randy Trox • Dave Belyea • Bob Baggett • Claudia Hill • Jessica Joye
List of handouts and presentation notes
• Appendix 1 – “Worth doing” rule changes list • Appendix 2 – Brian Rabe’s additional suggested rule changes • Appendix 3 – Marion County land use compatibility statement
Time Topic
10 a.m. Welcome and introductions 10:15 a.m. Review Nov. 2018 TRC minutes 10:30 a.m. Discuss committee rulemaking prioritization list
12 p.m. Lunch 1 p.m. Moving forward on drafting rules and subcommittees
2:30 p.m. Schedule future meetings 3 p.m. Adjourn
Alternative formats DEQ can provide documents in an alternate format or in a language other than English upon request. Call DEQ at 1-800-452-4011 or email mailto:[email protected].
Minutes Randy Trox opened the meeting at 10:00am.
• Noted the meeting is being recorded. • Reviewed the agenda for the meeting. • Introduced TRC members and others attending the meeting. • Announced he would be chairing the meeting, as there isn’t a committee chair appointed. • Informed the TRC that Jeannie Yackley resigned from the committee. • Asked for public testimony – nobody provided public testimony. • Requested the TRC review the minutes from the November 29, 2018 meeting.
o Connie Schrandt motioned to approve the minutes. Josh Graves seconded. o The TRC unanimously approved the minutes.
Before the meeting, TRC members individually ranked list of rule changes “worth doing,” “possibly worth doing,” “not worth doing,” and “unknown.” Randy Trox detailed which rule changes received at least four votes for “worth doing.” Four or more votes represented a broader level of support. 14 rule changes had four or more votes for “worth doing.” A list of those 14 rule changes were passed out as well as the results of the voting, Appendix 1. Randy reviewed each rule change proposal on the list with the TRC. Randy suggested that (as listed on Appendix 1) rule changes 2, 3, 5, 8 and 15 needed no further discussion, as the rule change could be drafted and discussed at a future meeting rather than other suggestions that will require discussion to draft rules. Randy also suggested that we add rule changes for subsurface drip systems and changes to certification, despite not getting four votes, as discussion in November meeting indicated the TRC felt they merited moving forward for more discussion. A question posed to the committee on November, 2019 rule adoption timeline, since DEQ”s policy option package did not move forward into the Governor’s recommended budget, so the timing of the rules with a fee increase has gone away. Feedback included:
• Josh Graves suggested the committee move forward aggressively. • Brian Rabe didn’t feel like we’re doing a cover-to-cover rule rewrite but still thinks we can get
through them. Should try systematically to get them done. Brian has provided additional proposed changes since the last meeting. He will send those to Randy.
• Randy Trox will send out Brian’s suggestions after this meeting, Appendix 2. • Josh Graves would like to get the rule changes done more quickly and could set aside a day a month
until they’re done. • Randy Trox will talk with rules coordinator about timing of rules and whether its problematic to
change later in the process. TRC discussed how difficult or how much discussion would be needed for the remaining rule changes. The TRC provided feedback on a scale from 1 to 10 with 1 being almost no discussion and 10 being considerable debate. The results: Procedural changes Technical changes #4 6 #7 3 #6 3 #9 3 #11 2 #10 1 #12a 6 (food carts) #14 5 #12b 3 (luxury toilets) Drip 9
#13 8 Cert 8 Randy is considering organizing calls as an alternative to a subcommittee meeting for those topics/rule changes that need more discussion - #4, #12a, #13, Certification, #14 and Drip. The TRC began addressing individual rule changes: #2 – Expand “major maintenance” definition to replace drop or distribution box as maintenance and not require a permit.
• Changes need to be same for same, not adding a box where none existed previously. • Replacing the existing equipment require SDS bond. • Discussed submitting paperwork of major maintenance activities. Some counties this would be a
burden to add these records, and if no permit there would be no interest in tracking them, as they are not involved.
TRC recommended to remove “cleaning” from the rule and add specifically “drop box” and “distribution box” #3 – Require ability for agent to add nitrogen sampling data for annual reporting in sensitive areas or to assure proper operation
• Need total nitrogen and nitrate • How/when to add nitrogen sampling? • Is this the same as treatment level 3? • Cost of sampling? Tank and effluent? • Cost per event (as per Josh Graves) is $200-$300 • When do you require sampling? What triggers it? • Is 340-071-0130(17) the right rule to change? • Could get blended results • What do we do with the outcome? • Would this be used in sensitive areas, GWMAs, special areas like south Deschutes, coastal lakes?
General agreement by TRC that this is not worthwhile moving forward as a stand-alone change. #5 – ESER – NAWT certification may be a good certification class, but no revocation option for certification if evaluator is dishonest or incompetent. Other certifications (installer or maintenance provider, for example) are revocable.
• These are for real estate transactions mainly, but not exclusively. • Would be great to promote installations that have access/cleanout ports • Clarified that this is to remove a NAWT certified person doing ESERs • Pumpers fall under this category who have gone out and got NAWT certified • Most NAWT are licensed pumpers, so adding licensing requirement with NAWT certification as
those that can do ESERs, then DEQ could use 340-071-600(9) – misuse of license to address issue. • Provides some enforcement leverage. • May be good to clarify form or rules if a seller refuses to allow exposing drainfield that is acceptable,
as long as the form clearly shows what was observed. General agreement by TRC to add Sewage Disposal Service license in addition to NAWT certification bullet in 340-071-0155, and license has ability for addressing fraud or incompetence. #6 – Change sewer availability rule to affirm that sewerage system owner is lead in determining sewer availability, as it occurs within their service boundaries and urban growth.
• Brittany May did not want to change 300’ part of the rule because it provides leverage on small urban-sized lots and city reluctant to require connection.
• Local agents and at times DEQ are made out to be the entity requiring sewer connection, when its actually the city or sewer district that requires connecting to sewer. The rule should be clear that the city must own the decision of legally and physically available.
• Todd Cleveland thinks it needs clarification only. • Bob Baggett suggests that the 300” part of the rule is meaningless. • City needs to be making that decision. • Require city to provide us notice if they are unwilling to provide sewer. • Could add application a requirement that applicant obtain sewer availability determination sign off
from city, if property in city or urban growth boundary. • If 300” rule removed, city would need to provide verification of sewer availability. • Marion County has Land Use Compatibility Statement form that has sewer availability, Appendix 3.
TRC did not reach agreement or conclusion on this issue/topic Committee discussed subcommittees and TRC meeting frequency. General agreement that phone calls on specific topics could be used between committee meetings. The phone meetings could also be webinars with shared screen and phone. Next two TRC meetings: February 12, 2019 – Salem ODFW office March 18, 19 or 20 – Salem ODFW office Meeting adjourned at 2:55pm.
State of Oregon Department of Environmental Quality
Onsite Technical Review Committee Appendix
1
2
3
4
5
6
7
8
9
10
A B C D E F GRule Citation Summary of rule change Why change is requested? Level of Impor Ease of Changing RFiscal Impact Possible Subc
340-071-0100
Expand 'major maintenance' definition to replace drop or dist box as maintenance and not require a permit.
These are often broken during the ESER inspections and to then make someone come in and get a permit after encouraging them to have their septic systems evaluated for time of transfer or maintenance is somewhat counterproductive. Worth Doing Easy
low Procedural
340-071-0130(17)
Require ability for agent to add nitrogen sampling data for annual reporting in sensitive areas or to assure proper operation.
Provide assurance that nitrogen reduction strategies are working. Existing rules potentially allow but are not clear.
Worth Doing Unknown
Procedural
340-071-0150
Add 10 year expiration to site evaluations Old site evaluation often involve extra time finding old approval area, sometimes with digging new pits and a site evaluation. Site or vegetation may be modified and staff changes make finding them difficult.
Worth DoingModerate Complexity
Procedural
340-071-0155
ESER - NAWT certification may be a good educational class, but no revocation option. May be good to clarify that if a seller refuses to expose drainfield that is OK as long as the form clearly shows what was observed. Consequence for false statements
Assure intent is being met. Rules allow to revoke certification for DEQ SDS license and certification. NAWT certification is intended to affirm individual attended class and no ability to revoke certification for fraud, incompetence, etc.
Worth DoingModerate Complexity
Procedural
340-071-0160
Change sewer availability rule to affirm that sewerage system owner is lead in deciding when sewer connection occurs within their service boundaries and urban growth b d i Ch h h i ll il bili
The sewerage system owner has control in the long term planning and funding of this infrastructure. This would have sewer providers determine distance and cost drivers.
Procedural
340-071-0220 Establish construction details for hydrosplitters
There is very little guidance on hydrosplitters and installers are making their own and not the ability to cite a rule if agent suspects there are issues. Worth Doing
Moderate Complexity
340-071-0220(6) 340-073-Eliminate of single-compartment dosing septic tan
Not enough retention time and solids retention in the tank
340-071-0290
ATT following seepage bed should consider sizing reduction and clearly state it’s an option.
Some agents have been doing this. Prior to ATTs in '05 only option was SF and didn't make sense to have seepage beds when BSF worked Worth Doing Easy
Technology
340-071-0290(6)(a)((F)
Graveless absorption method with HDPE or corrugated pipe
Currently limited to 12" PIP@43psi ASTM D-2241 and Infiltrator Quick4 LP.
Technology
11
12
13
14
15
A B C D E F G
340-071-0330
Nonwater-carried systems – eliminate need for DEQ approval or review for vault toilets at remote federal sites.
Low priority work with a lot of travel time. Often takes DEQ technical assistance to local agents on what to do.
Procedural
340-071-0340
Luxury Portable toilets/food cart wastewater…not regulated much. Should it be? Food cart pods should be connected to sewer if legally and physically available or connect to onsite system.
Luxury portable toilets can have large dump tanks. No regulations on where it can be dumped. Food cart pods not temporary and above ground tanks have been seen overflowing onto ground and into storm drains in Portland. Rules don't allow for external tanks at food carts but rule Worth Doing
Moderate Complexity
Procedural
340-071-0345
Create TS-3 Parts of the state, such as south Deschutes, groundwater management areas, coastal lakes where additional treatment is required. Worth Doing
Moderate Complexity
Technology
340-073
Update Products like pipe and filter fabric, establish hydrosplitter construction details.
Products like HDPE pipe is not currently allowed. Appears to be a preferred alternative (only pipe allowed for boring). Another example: Sand filter fabric standard is wrong (I’ve heard from suppliers). Hydrosplitters are allowed in rule but there should be some design criteria or other helpful information for plan review. Worth Doing
Moderate Complexity
Low to none Technology
OAR 340-071-0162 (14)Require certified maintenance providers on WPCF permits.
This is being incorporated to more WPCF permits to ensure qualified people are maintaining these systems. Worth Doing Easy
340-071-0100Rules require applicant to ‘sign’ application and agent to ‘sign’ permit.
Minor tweak to address digital age.
340-071-0100 & 340Rules infer that a cesspool is different than a seepage pit as far as absorption area goes.
where redundant to cesspool should be
340-071-0100(33) "Conditions Associated with Saturation" in accordance with OAR 340-071-0130(23) should both be (25)
340-071-0130
Require maintenance providers for all WPCF permits that have pressurized systems or ATT’s by not excluding these rules as exempt from WPCF permits.
WPCF permit writers are already including in permits in Schedule D. It would be a good thing if the rules backed us up.
340-071-0162(14)(
permittees are exempt from community system rules (OAR 340-071-0500). Is the exemption in Division 71 in place in deference to Division 52 which also covers community systems? A community system needs a responsible party and the equivalent of a sewer use ordinance in order to
What we have now is a rule for plan approval (Division 52) with requirements for community systems, and a rule for permitting (Division 71) that exempts 340-071-0220(1)(bWater table levels must be predicted using
standards in OAR 340 071 0130(23) Should be (25)
340-071-0650(4)(a
This rule allows someone to get certified w/class and exempt from examination, and that isn’t the intent. Either clarify a 1-time or delete rule (preferred), as the purpose was to address late 90’s when DEQ tried and failed to establish certification.
Situation that came up...Installer was certified installer. He took the test in '96, lapsed certification and coming to recertify.
340-073-0026 Remove steel tanks from the rules
No steel tanks being installed, many old steel tanks rotted
340-071-0265(2)(b)
Change to active voice and change from current wording to not before May 31 and no later than September 30 unless…
Keep it clear with no ambiguity.
340-071-0415(5)Clarify applicant is the owner and the lot is owned by individual owner
Not clear the applicant is the owner and could be abused.
Low to none Housekeeping
Low to none Housekeeping
None Housekeeping
Housekeeping
Housekeepingnone Housekeeping
Housekeeping
Low to none Housekeeping
None Housekeeping
None Housekeeping
State of Oregon Department of Environmental Quality
Onsite Technical Review Committee Appendix
1
2
3
4
5
6
7
8
9
10
11
A B C D E F G
Rule Citation Summary of rule change Why change is requested? Level of Importance Ease of Changing Rule Fiscal Impact Possible
Subcommittee
340-071-0100(33)(d) The word "grey" needs changed to "gray" to be
consistent with the cited reference (Munsell
Color Book).
typo Housekeeping Easy low Procedural
340-071-0100(43) The definition of "Designer" may need refined
to include qualifications.
Possibly Helpful Moderate Complexity low Procedural
340-071-0130(11)(a) Remove redundant language in fourth line
(second "the agent").
Housekeeping Easy low Procedural
340-071-0130(17) Current language states that the Owner is
required to submit the annual report and fee to
the DEQ.
Infers that submission by the service provider is optional.
However, language conflicts with 130(24)(f), which places
the responsibility of submitting the report and fee on the
service provider.
Possibly Helpful Moderate to DEQProcedural
340-071-0130(21) Replace "2000 Edition" with "current edition" as
it pertains to the Oregon State Pluimbing
Specialty Code.
Reduces chances for confusion when referenced codes
change.
Housekeeping Easy low Procedural
340-071-0130(25) Add language that defines recorded observations
of the highest level of a water table (temporary
or permanent) to be sustained for two or more
consecutive weeks (not simply the highest single
level observed).
Shorter term high levels are often associated with individual
storm events and may not persist long enough to correlate
with time required for formation of redoximorphic features.
Possibly Helpful Moderate Complexity low Procedural
340-071-0130(25) Change reference to "piezometers" to
"observation ports" to avoid issues with OWRD
and to be consistent with language for similar
devices used in drainfield trenches.
Worth Doing Easy low Procedural
340-071-0135(5)(b) Not sure of the purpose - seems to conflict with
prior approvals of both chambers and EZ flow.
Housekeeping Unknown low Procedural
340-071-0160(2)(c) Change "insure" to "ensure" typo Housekeeping Easy Procedural
340-071-0220(7)(h) New - "(h) Each absorption trench must be
equipped with an observation port near the
terminal end to enable measurement of liquid
levels throughout the full depth."
Without observation ports, determination of the liquid level
in trenches is an invasive process. This is especially
important as ESER's become more common.
Worth Doing
12
13
14
15
16
17
18
19
A B C D E F G
340-071-0265(2)(a) Textural class requirements for the cap material
should also allow one textural class coarser.
Natural soils typically get finer with depth so it would make sense
to allow the cap material to be slightly less fine than the natural
topsoil.
Worth Doing Easy Low
OAR 340-071-0520(3) Remove requirement for repair "units" adjacent
to initial units.
The so-called "checkerboard" requirement can be difficult to
implement since there are often initial cells on two or more
sides of the repair "unit" and locating underground elements
can be challenging years later. There is also a high risk for
compaction and other damage to the active drainfield
components during installation of the repair units.
Worth Doing Easy low
OAR 340-071-0520(4) Remove requirement to alternate between
absorption area units.
True duplex pump assemblies to a single hydrosplitter can
achieve the intent with dosing and resting without having to
"alternate" between units.
Worth Doing Easy low
340-073-0025(7)(e) Remove or broaden the range for the clear zone
in tanks downstream from the initial septic tank.
Dosing tanks, surge tanks, recirculation tanks, etc. will not
accumlate solids to the same degree or necessarily in the
same proportion as a primary septic tank.
Worth Doing Easy Low to none Technology
340-073-073-0055(4)(e) Consider changing the 20% maximum to
something more thoughtful. Could simply add
the standard "unless otherwise authorized by the
agent."
Other states (such as Idaho) require a minimum dose equal to
twice the volume of the pressure effluent sewer (to purge and
clean). Although rare, there are circumstances where such an
approach would exceed 20% of the design daily flow (e.g.,
long pressure transport pipes).
Worth Doing Moderate Complexity Low to none Technology
340-073-073-0055(4)(i) Delete "1" after the word "one" typo Housekeeping Easy Low to none Technology
340-073-073-0060(4)(d) Needs introductory statement, "When used as
distribution pipe, "
Current language infers that header pipes need holes, which
is not the case.
Housekeeping Easy Low to none Technology
340-073-073-0060 Add new section(s) for HDPE pipe (SDR 11 for
pressure transport pipe and SDR 17 for gravity
pipe).
HDPE pipe has been requested by entities (e.g., Oregon State
Parks) at times due to perceptions regarding sustainability.
Also, HDPE is also a very tough and durable material that is
typically heat-fused which is an advantage when doing
directional drilling across roads, wetlands, parking lots, etc.
Worth Doing Moderate Complexity Low to none Technology
20
21
22
23
24
A B C D E F G
340-073-073-0062? (New)Create a new section for Hydrosplitters Lack of rules has resulted in ambiquity when equipment
installed does not match the expectations of the agent.
Worth Doing Moderate Complexity Low to none Technology
340-073-0065(2)(e) Change "insure" to "ensure" typo Housekeeping Easy Low to none Procedural
Table 2? Require WRD to have well drillers respect
setbacks during well installation, not only for
existing systems but also for replacement areas
and approved areas.
In the past (and again recently), neighbors have been able to
negate an approval by simply drilling a well close to the
property line. The most recent example was right after the
affected party spent thousands of dollars on a formal
variance.
Worth Doing Unknown
State of Oregon Department of Environmental Quality
Onsite Technical Review Committee Appendix
HTTP://DEQSPS/PROGRAMS/RULEMAKING/WQ/ONSITE2019/DOCS/JAN2019MINUTESAPPENDIX3.DOCX Rev: 8/10, 04/12, 03/18
DIRECTIONS FOR COMPLETING A “LUCS” (LAND USE COMPATIBILITY STATEMENT)
FOR ON-SITE SEWAGE SYSTEMS WHAT IS A LUCS? The LUCS is the process Marion County uses to determine that Marion County permits and other approvals that affect land use are consistent with the local comprehensive plan. WHY IS LUCS REQUIRED? Oregon law requires activities that impact land use be consistent with local comprehensive plans. Permits for on-site sewage disposal systems cannot be issued until a favorable statement of land use compatibility is provided from the responsible local planning authorities. The LUCS cannot be approved until all requirements are met. WHEN IS A LUCS REQUIRED? A LUCS is required for: Site Evaluations OAR 340-071-0150, Construction – Installation OAR 340-071-0160, Alterations OAR 340-071-0160, Repairs OAR 340-071-0160, and Authorizations OAR 340-071-0205. NOT REQUIRED ON: Existing System Evaluations and Record Reviews. HOW TO COMPLETE A LUCS: URBAN PERMIT: (property is in an Urban Growth Boundary, zoned UT, or inside city limits) 1. Complete Section 1 of the LUCS. 2. The city planning office/official will complete Section 2 and sign. 3. If approved by the city, the LUCS form and complete application are then submitted to the Building
Inspection for review. A permit cannot be issued if the applicant does not comply with all applicable local land use requirements. The local jurisdiction will need to provide a favorable land use statement before Marion County can proceed with a permit application. ATTENTION: A LUCS CANNOT BE APPROVED AND SIGNED UNTIL ALL LOCAL REQUIREMENTS HAVE BEEN MET. CULTURAL RESOURCES PROTECTION LAWS: Applicants involved in ground-disturbing activities should be aware of Federal and State cultural resources protection laws. ORS 358.920 prohibits the excavation, injury, destruction or alteration of an archeological site or object, or removal of archeological objects from public and private lands without an archeological permit issued by the State Historic Preservation Office. 16 USC 470, Section 106, National Historic Preservation Act of 1966 requires a federal agency, prior to any undertaking, to take into account the effect of the undertaking that is included on or eligible for inclusion in the National Register. For further information, contact the State Historic Preservation Office at 503-378-4168, ext. 232.
MARION COUNTY BUILDING INSPECTION DIVISION
5155 Silverton Rd NE Salem OR 97305 (503) 588-5147
Fax: (503) 588-7948
HTTP://DEQSPS/PROGRAMS/RULEMAKING/WQ/ONSITE2019/DOCS/JAN2019MINUTESAPPENDIX3.DOCX Rev: 8/10, 04/12, 03/18
LAND USE COMPATIBILITY STATEMENT (LUCS) FOR ON-SITE SEWAGE SYSTEMS
DATE: ________________________ MCBI File #: _____________________ SECTION 1 – APPLICANT INFORMATION 1. Property Address: ____________________________ Property ID #: _____________________
____________________________
Section: ______Township: ______Range: ______Tax Lot #: __________ 2. Name of Applicant: _____________________________ Telephone #: ______________________
Mailing Address: ____________________________________________________________________
____________________________________________________________________
3. Describe type of facility the on-site sewage system will serve (business, residence or other):
❑ Single Family Residence
❑ Business
❑ Other: ________________________________
4. Type of on-site sewage system permit application being proposed for this property:
❑ New Installation Permit
❑ Repair Permit
❑ Alteration Permit for: ❑ Replacement Dwelling ❑ Bedroom(s) addition
❑ Other changes in land use involving potential sewage flow increase: ________________________
MARION COUNTY BUILDING INSPECTION DIVISION
5155 Silverton Rd NE Salem OR 97305 (503) 588-5147
Fax: (503) 588-7948
HTTP://DEQSPS/PROGRAMS/RULEMAKING/WQ/ONSITE2019/DOCS/JAN2019MINUTESAPPENDIX3.DOCX Rev: 8/10, 04/12, 03/18
SECTION 2 - TO BE FILLED OUT BY CITY OR COUNTY PLANNING OFFICIAL
5. The facility proposal is located:
❑Inside City limits ❑Inside UGB ❑Outside UGB 6. If inside the UGB, the proposed facility is subject to:
❑City jurisdiction ❑County jurisdiction ❑Shared city/county jurisdiction
7. Does the business or facility comply with local land use requirements? ? ❑YES ❑NO Comments: ___________________________________________________________________________________ ___________________________________________________________________________________ 8. Is a public notice and hearing required? ❑YES ❑NO DATE: _______________________ SANITARY SEWER AVAILABILITY DEQ OAR 340-071-0160 requires a permit application for onsite sewage disposal be denied if: A sewerage system which can serve the proposed sewage flow is both legally and physically available. * Physical Availability: A sewerage system shall be deemed physically available if its nearest connection point from the property to be served is:
• For a single family dwelling, or other establishment with a maximum projected daily sewage flow of not more than 899 gallons, within 300 feet;
• For a proposed subdivision or group of two to five single family dwellings, or equivalent projected daily sewage flow, not further than 200 feet multiplied by the number of dwellings or dwelling equivalents;
• For proposed subdivisions or other developments with more than five single family dwellings, or equivalents, the county agent shall make a case-by-case determination of sewerage availability.
EXCEPTION: A sewerage system shall not be considered available if topographic or man-made features make connection physically impractical. * Legal Availability: A sewerage system shall be deemed legally available if the system is not under a DEQ connection permit moratorium, and the sewerage system owner is willing or obligated to provide sewer service. 9a. Is a sewerage system physically available and legally available to serve this property?
Physically available: ❑YES ❑NO Legally available: ❑YES ❑NO 9b. If service is not available, please explain why and when service may become available:
_______ _______
HTTP://DEQSPS/PROGRAMS/RULEMAKING/WQ/ONSITE2019/DOCS/JAN2019MINUTESAPPENDIX3.DOCX Rev: 8/10, 04/12, 03/18
SIGNATURES
CITY OF PLANNING OFFICIAL:
_____________________________________ _____________________________________ (Print Name) PLANNING OFFICIAL (Signature) _________________ _____________________________________ _______________________ DATE ADDRESS TELEPHONE # * COUNTY PLANNING OFFICIAL
_____________________________________ _____________________________________ (Print Name) PLANNING OFFICIAL (Signature) ________________ ____________________________________ _______________________ DATE ADDRESS TELEPHONE # * If necessary, depending upon city/county agreement on jurisdiction outside city limits but within UGB.