Report (105) Clean Water Services File Number
5
CleanWatei Services " "
Itttti=�1; ;ti ensjtive Area Pre-Screening Site Assessment : , ..
1. Jurisdiction: t 0 / /14.8D
2. Property Information(example 1S234AB01400) 3. Owner Information 9 2018
Tax lot ID(s): j I o qcc' 0 Y/00 Name:
Company: CITY (4-
) )� Address: (. t t j(v ),4Pj Ft )r
QB Site Address: /J�z2_ .tt� r/ %,c'+� (—It
City,State,Zip:
City,State,Zip: 7i fr9eD 97Z2-3 Phone/Fax:
Nearest Cross Street: E-Mail:
4. Development Activity(check all that apply) 5. Applicant Information
❑ Addition to Single Family Residence(rooms,deck,garage) Name: 7 '7 - vi)
k ❑' Lot Line Adjustment ❑ Minor Land Partition Company:—ILL /t(A4eu-J,"L (�t`S
❑ Residential Condominium ❑ Commercial Condominium Address: 1,3 S
U Residential Subdivision ❑ Commercial Subdivision
CI Single Lot Commercial ❑ 0 Lot Commercial City,State,Zip: � ��� ?ate S
Other c-Cwi rhritr A) 7 pa Phone/Fax: 5CQ'.-74,0— (7e .5-S�
I4A�p%v7 E-Mail: coy.ehictEhi loli9('A.)(,1715•C --
6. Will the project Involve any off-site work? Q Yes Wio ❑Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project 28& Zr
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 at 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 inlormali'' • •ined in this document,and to the best of my knowledge and belief,this information complyte,and accur te.
Print/Type Nae ` • ?"-ti-A4 r� Print/Type Title /C - f f ftJ
Signature •.at. Date 7-4, —✓e
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.
g.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.
❑ 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 17-05,Section
3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law.
rekThis Service Provider Letter is not valid unless I CWS approved site plan(s)are attached.
El The proposed activity does not meet the definition of development or the lot was platted atter 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE
PROVIDER LETTER IS REQUIRED. �+
Reviewed by - ``� ,-1 ,� --- Date 7. !q
• /
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
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SOMMERVILLE AND BURLESON BLUE MT. POOLS
RESIDENCE 13121 S. WARNOCK RD. '
13922 SW HILLSHIRE DRIVE OREGON CITY, OREGON 97045
TIGARD OR 97223