Report M Zoo 00 O i
File Number
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Sensitive Area Pre - Screening Site Assessment
Jurisdiction T, , Date �J J / 3iZ av
Map & Tax Lot. � / / A, 5 , p ) 7 00 Owner rvc P it 1/14.4 s (4x v /561
Site Address /S j j,kl 79 -A ,4
I 1 : J � D a.✓'ot ('12 g 7 2. , 4- Contact ‘,;.
t/
Proposed Activity i Address
i x2 l.. f46 (e 2.4 -033
((a■r�e -� e— Phon L�11 zSO - !S l
Official use only below this line
Y N NA Y N NA
IX I n Sensitive Area Composite Map n 1 1 Stormwater Infrastructure maps
Map# 251w QS# y 52.\
Y N NA Y N NA
1 � n rg Locally adopted studies or maps ( ((D n 1 Other
Specify Specify C 4,S t /e //J
Based on a review of the above information and the requirements of Clean Water Services
Design and Construction Standards Resolution and Order No.,00 -7: -
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1 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 PERMIT. If Sensitive Areas exist on the site or
within 200 feet on adjacent properties, a Natural Resources Assessment Report may also
be required.
[. 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.
n The proposed activity does not meet the definition of development. NO SITE
ASSESSMENT OR SERVICE PROVIDER LETTER IS REQUIRED.
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Comments: /� ,d
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Reviewed By: / / Date: -/ q
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