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CWS-SPL -� � Clean Water Services File Number C1eariWater` Services 17-000532 Sensitive Area Pre-Screening Site Assessment 1. Jurisdiction: Tigard 2. Property Information (example 1S234AB01400) 3. Owner Information Tax lot ID(s): Name: Mary Kastel 2 S 1 11BB tax lots 600,900 and 1100 Company: Address: 14259 SW 100th Ave Site Address: 14259 SW 100rd Ave City,State,Zip: Tigard,OR,97224 City, State,Zip: Tigard,OR,97224 PhonelFax: Nearest Cross Street: SW View Terrace E-Mail: 4. Development Activity(check all that apply) 5. Applicant Information U Addition to Single Family Residence(rooms,deck,garage) Name: David Bantz U Lot Line Adjustment U Minor Land Partition Company: Westlake Consultants,LLC P Y� U Residential Condominium U Commercial Condominium Address: 11515 SW Sequoia Parkway • Residential Subdivision U Commercial Subdivision Tigard,OR,97224 U Single Lot Commercial U Multi Lot Commercial City,State,Zip: Other PhonelFax: 5036840652 E-Mail: dbantz@westlakeconsultants.com 6. Will the project involve any off-site work? ❑Yes No U Unknown Location and description of off-site work 7. Additional comments or information that may be needed to understand your project This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits,DEQ 1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands andlor Department of the Army COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law. By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority to enter the project site at all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify that I am familiar with the information contained in this document,and to the best of my knowledge and belief,this information is true,complete,and accurate. PrintlType Name David Bantz PrintlType Title Planning Specialist ONLINE SUBMITTAL Date 2/17/2017 FOR DISTRICT USE ONLY ❑ Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report may also be required. ❑ Based on review of the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200'of the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,State,and federal law XBased on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas it they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law. ❑ This Service Provider Letter is not valid unless CWS approved site plan(s)are attached. ❑ The proposed activity does not meet the definition of development or the lot was platted after 9/9195 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED. Reviewed by Date 2/20/17 2554 SW Hillsboro Highway • Hillsboro,Oregon 97123 • Phone:(503)681-5100 • Fax:(503)681-4439 • www.cleanwaterservices.org ,�--, 015L ; I1---K ' N '' i , j�1b0} 1 IMO Scale 1 =50 � 1 1 v • • • - - - - - - r 88 ' 87..' . ' ,;2.s' 1/: ' 6t.- \,..0 2.0'—9 + —.6=1 44? + I I wi \ Q8j 4. _ _ - ti 1 LQ ;+ i I \'-------„A , 7), I A' I , yf 1 9, 08: k 1 0,075 F d e g #0 SF 8 Oil0 . N: 373 ,g 1 lj ,H. � l ,r6, S �1 _ , I N- • cPIIIIMOMI •jill 11, 1 MIA 1 1 if II pit .rmi.,.. , e 0;1 , \ _ —01011=10 fir~ ,s.+ ' i - 4 - f--- Li__ , rr §5 Nis "11111111111. :T . � ,��t Cut s• i ...prii Allir...'-;) ba}airing • � �– �,�� ^�'` >��berig ��„` � �`-_.—.�` ail 61111111.11 f ref~ r ► _� -i �'�►' ►��ir�1te► ► � , 1 .. .► .�LThIG tiZion—wilillrfe“wwist'"0111111i ' I 1 6. 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