Report . — PvH 2623— 00247 RECEIVED
JUN 2 0 2023 C1eanWaterrA Services
SENSITIVE AREA PRE-SCREENING SITE •.i1gg5icolT jH
Clean Water Services File Number 23-001843
1. Jurisdiction: Washington County
2. Property Information(example: 1S234AB01400) 3. Owner Information
Tax lot ID(s):
Name: Matt Deblock
14900 SW 98TH AVE Company:
Address: 14900 SW 98TH AVE
OR Site Address: 14900 SW 98TH AVE City,State, Zip: TIGARD,OR,97224
City, State,Zip: TIGARD,OR,97224 Phone/fax: 5034843278
Nearest cross street: Email: mattdeblockl@gmail.com
44. Development Activity(check all that apply) Applicant Information
171 Addition to single family residence(rooms, deck, garage) Name: Matt Deblock
ElLot line adjustment ElMinor land partition Company:
❑ Residential condominium D Commercial condominium Address: 14900 SW 98TH AVE
❑ Residential subdivision 0 Commercial subdivision City,State,Zip: TIGARD,oR,97224
❑ Single lot commercial ❑ Multi lot commercial Phone/fax: 5034843278
Other Septic to Sewer Email: mattdeblock1@gmail.com
6. Will the project involve any off-site work? ❑Yes 1 No 0 Unknown
Location and description of off-site work:
7. Additional comments or information that may be needed to understand your project:
We need to move off of our septic tank and onto the city sewer
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 and/or 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.
Print/type name Matt Deblock Print/type title
Signature " Date
. 6/15/2023
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 19-5, Section
3.02.1,as amended by Resolution and Order 19-22. All required permits and approvals must be obtained and completed under applicable
local,State and federal law.
❑ Based 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 if they are subsequently discovered.This document will serve as your Service
Provider Letter as required by Resolution and Order 19-5,Section 3.02.1,as amended by Resolution and Order 19-22.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 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT
OR SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed by %�T��.Q/�i Date 6/16/2023
Once complete,e ail to:SPLReviewcecleanwaterservices.org Fax: (503)681-4439
OR mail to: SPL Review,Clean Water Services,2550 SW Hillsboro Highway, Hillsboro,Oregon 97123
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