Report (80) •,, _ Co--no ./ .210 (I It 712 5 A iriv I
Clean Water Services File Number
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C1eanWater\ Services I / • ,r ,, ,_
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Sensitive Area Pre-Screening Site Assessment "
1. Jurisdiction: 1.
JAN 3 2t
2. Property Information(example 1S234AB01400)
3. Owner Information w i
Tax lot ID(s): .3,..5103/90 J'r'G Name: i u I QR.,_
n .i '1 C t" r -(1;4--
Company: 1 ,I`t 1 ,, Xt 14t: ti4
,
_ Address: U I Cj "T 4,
D@ Site Address: '/ r e
/ 2) j f c- .t~..,j r C 1 <,-t City, State,Zip: 2 , ' f
City,State,Zip: T (�c�( t`cj tr. P. 7 72j_j Phone/Fax: ;.56 c1,5"&
Nearest Cross Street: � �L°�
( I Z_ �., E-Mail: Ga lel d,V-Q Lt)V` 1 E' KE7Y t-' ci.C., I d
4. Development Activity(check all that apply) 5. Applicant information
A Addition to Single Family Residence(rooms,deck,garage) Name: t I IAA j 1 4
C ek&r
❑ Lot Line Adjustment ❑ Minor Land Partition
Company: "'W
U Residential Condominium
❑ Commercial Condominium tt t
❑ Residential Subdivision Address: t 1 I et.) --,(, - E yf-of '— -
❑ Commercial Subdivision > f
❑ Single Lot Commercial ❑ Multi Lot Commercial City, State,Zip: i ��L:L t C) Clj
Other Phone/Fax:
E-Mail: i 0,1417) €ekev-ez, i ! i, e, c -
•
6. Will the project involve any off-site work? Yes sd,No ❑Un own f j'•
Location and description of off-site work Ct d r VC---/
k,Ct����� Y `�k,Y— '.1- l.(-? e.r f 1.C_..
7. A ditto al com ents o nformatio t tat maybe needed to-urylerstand your pro ect A c , 1k_,1) I c} g;
-To 0(-- ct 1 I }1 kik, e. -c Cc.l._ -i* .) _ e t; r i�?C CG�t1C r t� Yui
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This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Buildtnn 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 th'sdocument,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name _[. 1 iv) f y{{t C" 'key',•- Print/Type Title
Signature fir. f/( E:is 2_.
Date Sy/r/26"l 7
FOR DISTRICT USE ONLY
Li 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 17-05, 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 if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 17-05,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 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE
PROVIDER LETTER ISISREQUIRED.
Reviewed by /4' 4,...9...��-�,�....._.° Date if ' if. /7
Once complete, email to: SPLReview@cleanwaterservices.org • Fax: (503)681-4439
OR mail to: SPL Review, Clean Water Services,2550 SW Hillsboro Highway, Hillsboro, Oregon 97123
Revised 6/2017