Report (99) tr1�e
Clean Water Services File Number
CleanWater Services 18-001587
Sensitive Area Pre-Screening Site Assessment
g
1. Jurisdiction: Tigard
2. Property Information(example 1 S234A801400) 3. Owner Information
Tax lot ID(s): Name: Jerry and Tracy Nesseth
Company: ���
Address: 13355 SW 76th Avenue it';‘ n� �L � try
Site Address: 13355 SW 76th Avenue City,State,Zip: Tigard,OR,972J
City, State,Zip: Tigard,OR,97223 Phone/Fax: (503)686-0793
Nearest Cross Street: SW Fir Street E-Mail: ferry@oregonadventures.org
4. Development Activity(check all that apply) 5. Applicant Information
(,A Addition to Single Family Residence(rooms,deck,garage) Name: Jerry and Tracy Nesseth
U Lot Line Adjustment ❑ Minor Land Partition Company:
U Residential Condominium ❑ Commercial Condominium Address: 13355 SW 76th Avenue
❑ Residential Subdivision ❑ Commercial Subdivision Tigard,OR,97223
❑ Single Lot Commercial U Multi Lot Commercial City, State,Zip:
Other Phone/Fax: (503)686-0793
E-Mail: ferry@oregonadventures.org
6. Will the project involve any off-site work? ❑Yes all No U Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
We are adding a RV size garage to our existing home and extending the driveway pad to access the new garage.
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 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 this document,and to the best of my knowledge and belief,this information is true,complete,and accurate.
Print/Type Name Jerry and Tracy Nesseth Print/Type Title
ONLINE SUBMITTAL Date 5/16/2018
FOR DISTRICT USE ONLY
U 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.
isif 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
07-20,Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law.
U 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 PROVIDE' ER IS REQUIR'•.
Reviewed by air a fir` • ,. Date 05/18/18
2550 SW Hillsboro Highway • Hillsboro.Oregon 97123 • Phone. (503)681-5100 • Fax (503)681-4439 • www.cleanwaterservices.org