Report (42) eiP"',t
MSTt_oict vta2.-'1g
Clean Water Services File Number
CleanWateer Services 11-00 2 5 37
Sensitive Area Pre-Screening Site Assessmelf
RECEIVED
1. Jurisdiction: Tigard
2. Property Information(example 1S234AB01400) 3. Owner Information A U G 1 9 2019
Tax lot ID(s): 26102 Cr) DZ4'Oci Name: Karl Petersen PITY OF TIGARD
Company: BUILDING DIVISION
Address: 9610 sw hillview ct
Site Address: 9610 SW Hillview CT City,State,Zip: tigard,ore,97223
City,State,Zip: tigard,Oregon,97223 Phone/Fax: 503 890-2411
Nearest Cross Street: Omara E-Mail: karippm18@gmail.com
4. Development Activity(check all that apply) 5. Applicant Information
Iii) Addition to Single Family Residence(rooms,deck,garage) Name: karl petersen
❑ Lot Line Adjustment ❑ Minor Land Partition
IJ Residential Condominium Company:
❑ Commercial Condominium Address: 9610 sw hillview ct
❑ Residential Subdivision Li Commercial Subdivision
LiSingle Lot Commercial IDMulti Lot Commercial City, State,Zip: tigard,ore,07223
Other Phone/Fax: 503 890-2411
• E-Mail: karippm18@gmail.com
6. Will the project involve any off-site work? ❑Yes &j No ❑Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
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 andlor 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 karl petersen Print/Type Title
ONLINE SUBMITTAL Date 7/23/2019
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
IRVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
S
ay 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 -
- Senstnve Areafre=Screentng-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 SiteAssessment 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 activi does •t meet the definition of development or the lot was platted after 9/9195 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVIC` •Re t, RLE ER IS: .*UIR.,B.
Reviewed b 11 Al _444 ALI6lq/2J °1
m�:.�e� Date y
2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • Phone:(503)681-5100 • Fax (503)681-4439 • www.clean waterservices.org