Report MST kg- Tc
Clean Water Services File Number
C1eanWater Services 19-001008
Sensitive Area Pre-Screening Site Assessmen! ►ECEIVED
1. Jurisdiction: '' APR — 2 2019
2. Property Information(example 1S234AB01400) 3. Owner Information CITY OF TIGARD
BUILDING DIVISION
Tax lot ID(s): Name:
2910306011H Company:
Address: 21100> 0,31 gotSite Address: sw DI St City, State,Zip: r g, , Oregon,9722::
City, State,Zip: (Dreg o 97222 Phone/Fax:
Nearest Cross Street: iecie -n E-Mail:
4. Development Activity (check all that apply) 5. Applicant Information
Lia Addition to Single Family Residence(rooms,deck,garage) Name: Pie "•.
❑ Lot Line Adjustment (❑ Minor Land Partition Company WI Hn<:
❑ Residential Condominium ❑ Commercial Condominium Address:
00 ft:A 23063')
U Residential Subdivision ❑ Commercial Subdivision
❑ Single Lot Commercial EJ Multi Lot Commercial City, State,Zip: T .Or1281
Other Phone/Fax: SOS 800-763:i.
E-Mail: .,, a Bo;_t _onti o,.corn
6. Will the project involve any off-site work? ❑Yes J No U Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
sf d tics,on beck of rouse
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 PHiPPe AVesse Print/Type Title President
ONLINE SUBMITTAL Date 3/77/2019
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.
1. 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 Ste 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.
® This Service Provider Letter is not valid unless 1 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 IS REQUIRED.
Reviewed by - Date 4/2/19
2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • Phone: (503)681-5100 • Fax:(503)681-4439 • www.cleanwaterservices.org
` The
_ _ _ _ 82.5' Design
.. Department
202 ' 1 Creating Your
1 1 Perfect Space
I ._.Y I Pat Sauer
ILOT COVERAGE: I Designer
LOT AREA: 21,749 SQUARE FEET PO Box 69
1 1 Lake Oswego,Oregon
I I 97034
EXSITING HOUSE: 907 SQUARE FEET 503 332 3796
EXISTING COVERED DECKS: 109 SQUARE FEET
PROPOSED CONSTRUCTION: 224 SQUARE FEET
II
I
1 TOTAL EXISTING: 1,016 SQUARE FEET 1
ITOTAL PROPOSED: 1,240 SQUARE FEET
GRAND TOTAL LOT COVERAGE: 2,256 SQUARE FEET 1
••
I
'
202
w1 1
ABBREVIATIONS I N I
+- M
(/D N
(N)=EXISTING I
36"DIAMETER DOUGLAS FIR _ J .., N
(N)=NEW 1 • PROTECT WITH APPROVED FENCING 1 iOlI I
DURING CONSTRUCTION i
I I' c cD
N O
1 PROPOSED 224 S.F.1 STORY ADDITION 1AO
F.F.@ 12"ABOVE EXISTING GRADESia
198 1 @ REAR 1 O
C/1
\ ,, O bA
1 1 8
Ii ..,, i, 16'-1" 1L16'-1 1/2" 16'-0" I
1 �1
4 XXX
`' W
T� X
L — �:: ' P4
1 X CRAWL ACCESS
WELL(N)
196 I XX Xr
`\I I STORY �., X
\ 1 IIS
' (E)
I "' '3 1/2" i 32-2 1/2" .X X* Site Plan
1 1 COVERED 1
1 General Notes
i \ i'PORCH E
CWS FILE NO. i q•00/00 w ( \ I REVIS I ONS
Approved
Clean Water Services DRIVEWAY
FOR ENVIRONMENTAL REVIEW `,' 1 (E) 1 03.22.19
By Cf3- Date L{•.g-1`J ensi DATE
SPL ATTACHMENT 1 OF f PLANTING 1 10.25.18
ARE
.TI PROJECT NO:
- - - - - - - -fir %- -
4818
SIDEWALK(E) Q I /
SHEET
WATER METER a I TRANSFORMER -i
SW WALNUT ST. ' 0
4 SITE PLAN Ak
SCALE:1"=20' \Nj