Plans ' u A 44 File Number 1 mi
Sensitive Area Pre - Screening Site Assessment
Unified Sewerage Agency 00-63 r
of Washington County
• Jurisdiction i3 ' Date & -26 -(J
Map & Tax Lot 26 1 i Z 6 2 Owner
Site Address
Contact
Proposed Activity
Acia . � �- t t ( 7�'� > Address
Phone —�?
Y N NA Y N NA
)g(Ei ❑ Map # omp� i Map ❑ ❑ St # w er In rastructure maps
❑ ❑ Locally adopted studies or maps ❑ ❑ oc Other
Specify Specify
Based on a review of the above information and the requirements of USA Design and
Construction Standards Resolution and Order 00 -7:
❑ Sensitive areas potentially exist on site or within 200' of the site. THE APPLICANT
MUST PERFORM A SITE CERTIFICATION PRIOR TO ISSUANCE OF A SERVICE
PROVIDER LETTER OR STORMWATER CONNECTION PERMIT. If Sensitive Areas
exist on the site or within 200 feet on adjacent properties, a Natural Resources
Assessment Report may also be required.
x Sensitive areas do not appear to exist on site or within 200' of the site. This pre-
screening site assessment does NOT eliminate the need to evaluate and protect
water quality sensitive areas if they are subsequently discovered on your
property. NO FURTHER SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS
REQUIRED. THIS FORM WILL SERVE AS AUTHORIZATION TO ISSUE A
STORMWATER CONNECTION PERMIT.
The proposed activity does not meet the definition of development. NO SITE
ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED.
Comments:
0 17'i cr i ., - 3 - 12 i . N -,6itc: ei i(0 - - vL, a4ea_,)
Reviewed By: 1 : '4 / d = ` / Date: -l- S--Cy
Retur, to Applicant
Mail 7 f Fax Counter
Date 14 - ''r� By �;
MAY-12-01 02:10 AM JTG.1NC. 5036966666 F.01 '
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