Report (19) H6-r--- )/ Le - do 37 3
Clean Water Services File Number
CleanWater Services 16-003538
Sensitive Area Pre-Screening Site Assessment
1. Jurisdiction: Tigard
2. Property Information(example 1S234AB01400) 3. Owner Information
Tax lot ID(s): Name:
Company:
Site Address: 16145 sw Crimson cte,Zip: Keizer,OR,97307
City,State,Zip: Tigard,Oregon, ax:
Nearest Cross Street: Serena Way - ail: eli.tipikin@gmail.com
4. Development Activity(check all that apply) •. Applicant Information
[j Addition to Single Family Residence(rooms,deck,garage) Name: Elya Tipikin
-2 ❑ Lot Line Adjustment ❑ Minor Land Partition Company: Grey Stone Construction LLC
❑ Residential Condominium ❑ Commercial Condominium Address: PO box 20098
.4
❑ Residential Subdivision Li Commercial Subdivision
❑ Single Lot Commercial ❑ Multi Lot CommercialCity, State,Zip: Keizer,OR,97307
Other Phone/Fax: eli.tipikin@gmail.com
, .rE-Mail: eli.tipikin@gmail.com
d' 6. Will the project involve any off-site work? ❑Yes III No ❑Unknown
Location and description of off-site work
7. Additional comments or information that may be need • to understand your project
This application does NOT replace Grading and Erosion Contro ermits,Connection Permits,Building Permits,Site Development Permits,DEQ
1200-C Permit or other permits as issued by the Department o Environmental Quality,Department of State Lands andlor Department of the Army
COE. All required permits and approvals must be obtained i d completed under applicable local,state,and federal law.
By signing this form,the Owner or Owner's authorized agent• representative,acknowledges and agrees that employees of Clean Water Services have authority
to enter the project site at all reasonable times for the pu a 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 ment,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name Elya Tipikin Print/Type Title Owner
ONLINE S MITTAL Date 9/22/2016
FOR DISTRI E ONLY
❑ Sensitive as potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A
SE E PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
ay 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
(--,\p approvals must be obtained and completed under applicable local,State,and federal law.
`-'0 ❑ 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 su - I discovered.This document will serve as your Service Provider letter as required by Resolution and Order
07-20,Section 3.02.1. •uired permits and ap• • als must be obtained and completed under applicable local,state and federal law.
1=1 This Se _ •rc --'-"-."---"--"J.._.___
2
,, ,, ,.ti___,_ CWS approved site plan(s)are attached.
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The proposed ac..-...; ..r:::... ..:..71-7.,...,,,....... • . 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 Date 09/23/16
2550 SW Hillsboro Highway • Hillsboro. Oregon 97123 • Phone i503i 631-5100 • Fax_ 333, 381-4439 • \n,',\,‘\. cleanwaterseroices_org