Report -�/ Clean Water Services File Number
CIeaii\'k ter Services 1( 19-000338 :�,I
Sensitive Area Pre-Screening Site Assessment
1. Jurisdiction: (fel,.....,./1 7 TIGARD FEB 2019
F IGARO
2. Property Information (example 1S234A801400) 3. Owner Information I IO
Tax lot iD(s): 25/08 D d01400 Name:
i�liT�.PNG VI,
Je-ffs * kokYG V1/4 . o y
Company:
Address: /5.2 AC J W Pr;ASO i.y- A-04-
QB Site Address: /5.2W S W /4/;5,500,y: Avg City. State, Zip: r;,....„0( , c 97. 22y _
City, State, Zip G'v . 2 Phone/Fax:
Nearest Cross Street: S.W. je;11 a Or• E-Mail:
4. Development Activity(check all that apply) 5. Applicant information n
-Addition to Single Family Residence(room• deck .arage) Name: 5+ ,v e„ Ry.41 e. �.e_
❑ Lot Line Adjustment ❑ Minor Land •artition
Company: R i c.Kf C445 1-014.1, rrirrGlA4".„
❑ Residential Condominium 0 Commercial Condominium Address: `/Sy3 c5.E. TT u, 141w r
❑ Residential Subdivision 0 Commercial Subdivision
0 Single Lot Commercial la Multi Lot Commercial City, State. Zip; ,4'Its', I Ul, et f23
Other Phone/Fax: 80 3- 972-6 5e t
E-Mail:s. 'awe . �u.4tt4a.di),IWakj-Cooled", +n.
6. Will the project involve any off-site work? ®Yes rot No ❑Unknown
. Location and description of off-site work
—
7. Additional comments or information that may be needed to understando{�r project •�
Aid 10' x2'.1.' Deck "b Et.; nt L c,k ._-._ Elainv.s 1$`xi8"1R'
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,stale,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 authoriPj 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 docum nt.and 0 the best of my knowledge and belief.this information is true,complete.and accurate.
Print/Type Name ��-cov 4l t t-G— Print/Type Title (,v" p(r etc(1 lir 16Y"'
Signature _ Date /—e7C)--1
FOR DISTRICT USE ONLY
j 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 or adjacent properties,a Natural Resources Assessment Report may also
be required.
j 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 avaiable information the above referenced project will not significantly impact the existing or potentially
sensitive area(s)found rear the site.This Sensitive A-ea Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water gLality I
sensitive areas it 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.
A This Service Provider letter is not valid unless 1 GWS approved site plans)are attached.
4 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 IS REQUIRED. SEE POLYGON AT BULL MOUNTAIN PLAT
Reviewed by JP:Pr *,_ __ Date 2/4/19
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
i
RICK'S Name
411111111.111112Ein phone No. ci 4 q
www.RicksFencing,com Email
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CWS FILE Na /7-000336
Approved
Clear)Water Services
FOR VIRONMENTAL REVIEW
194 YF Z-e-(A/L -c‘t\"Aot/r- :\"Cv‘P. LS 4444 t i r CA j By Date •€117
SPL A A HMENT 1 OF j
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