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Report
Apr.21. 2004 3 :08PN1 CLEAN WATER SERVICES 503 8463525 No.1229 P. 1 fi r`', sT ?�, / IP 17 j jj t �.rl f� Filc Number F-;.17 CleanWater Services. Otn cuaYm a ittli4rtt iS ate t. (E Y Sensitive Area P creening Site Assessment Jurisdiction C; 1 c Date 6 4 4 4 Map & Tax Lot ! 3 o Wel ,... �— Owner Site Address 11 0934 Ski * _. .� .} ©g. Contact .. av�• Proposed Activity `.J - Address / p • j , Cth A — Phone Pke OR. 97- f, � 17 Official use only below this line Y N NA Y N NA Sensitive Area Composite M. p , Stormwatex Infrastructure maps 0 El Map # 151 W O 0 ❑ ' ►• QS # `fig ❑ [1 Locally adopted studies or maps ❑ ❑ Other • IN Specify _. Specify .4•. ,a-,a / Based on a review of the above information and the requirements of Clean Water Services Design and Construction Standards Resolution and Order N0.404446 q sima ❑ 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. 2 Sensitive areas do not appear to exist on site or within ZOA' 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: L� = f d��✓ir2 fly 5eas:r:_vr 4re,. _ . t Rev iewe d Bye - Date: L// 4 3/G V Retur • , .a Applicant Post -IV bra fax transmittal memo 7671 I tetmos Mail Fax a . Counter _ To tk Co. co. c 5 dept. Pnonefl °3 68 / +