Report nis7"202D -OoaSs
Clean Water Services-Service Provider Letter
Submission Date: 1/15/2020 Confirmation#: 339
Applicant Name: Stan Moore Review Type: Partner City Plan Review
Contact Email: stan@mooredecks.com Ground Disturbance: 75 Sq.Ft.
Contact Phone: 503-522-0047 New Impervious Area: 0 Sq.Ft.
Primary Address: 13260 SW HAZELCREST WAY - Mod.Impervious Area: 0 Sq.Ft.
Primary Jurisdiction: Tigard Development Activity: Single-Family Dwelling Addition
Affected Tax Lots: 251090606300
INSTRUCTIONS:This pre-screening report is the Service Provider Letter(SPL)as required by Resolution and Order 19-5,Section
3.02.1,as amended by Resolution and Order 19-22.PROVIDE A COPY OF THIS SPL TO THE JURISDICTION RESPONSIBLE FOR LAND
USE REVIEW AND PERMIT ISSUANCE.This pre-screening review does NOT eliminate the need to evaluate and protect water quality
sensitive areas if they are subsequently discovered and this review does NOT eliminate the need to obtain additional CWS permits
or reviews if project changes in scope or location.All required permits and approvals must be obtained and completed under
applicable local,State and federal law.
Permit or Review I Required Next Steps
Environmental Site Assessment No
Review
Water Quality Treatment Review and TBD Contact city(primary jurisdiction)responsible for land use review and permit
Stormwater Inspection issuance.
Erosion Control Inspection Permit TBD Contact city(primary jurisdiction)responsible for land use review and permit
issuance.
Erosion Control Inspection Permit TBD Contact city(primary jurisdiction)responsible for land use review and permit
with Site Plan issuance.
Line Tap Inspection Permit TBD Contact city(primary jurisdiction)responsible for land use review and permit
issuance.
Disconnection Permit TBD Contact city(primary jurisdiction)responsible for land use review and permit
issuance.
Connection Permit TBD Contact city(primary jurisdiction)responsible for land use review and permit
issuance.
Connection Permit with Plumbing TBD Contact city(primary jurisdiction)responsible for land use review and permit
Plan Issuance.
Easement Review TBD Contact city(primary jurisdiction)responsible for land use review and permit
issuance.
The CWS Development Services group is here to review your project in the most effective and efficient way,while protecting the Tualatin River Watershed.Our
partners include municipalities,environmental organizations,and developers large and small.
Contact Us•2550 SW Hillsboro Highway•Hillsboro,Oregon 97123
phone:503-R1-5100•email:spireview@cieanwaterservices.org•website:www.deanwaterservices.org/permits-development
Clean Water Services File Number
CleanWaterr Services
Sensitive Area Pre-Screening Site Assessment
1. Jurisdiction: Tigard
2. Property Information (example 1S234AB01400) 3. Owner Information
Tax lot ID(s): Name: Robert Sellman
Company:
Address: 13260 SW Haze!crest Way
S28 Site Address: 13260 SW Hazelcrest Way City, State,Zip: Tigard,Oregon,97224
City,State,Zip: Tigard, Oregon,97224 Phone/Fax:
Nearest Cross Street: Bull mountain E-Mail:
4. Development Activity(check aft that apply) 5. Applicant Information
la Addition to Single Family Residence(rooms,deck,garage) Name: Stan Moore
❑ Lot Line Adjustment 13 Minor Land Partition Company: Stan Moore Construction
❑ Residential Condominium ❑ Commercial Condominium Address: 6107 SW Murray Blvd. 263
❑ Residential Subdivision ❑ Commercial Subdivision
la Single Lot Commercial 13 Multi Lot Commercial City, State,Zip: Beaverton, Oregon, 97008
Cther Phone/Fax: 503-522-0047
E-Mail: stan@mooredecks.com
6. Will the project involve any off-site work? ❑Yes 112 No 13 Unknown
Location and description of off-site work
7. Additional comments or information that may be needed to understand your project
Building a proposed 32ft.x 9ft.deck on back of house.Existing 16ft.x 9ft.deck to be removed.
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 al 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 Stan Moore Print/Type Title Owner
Signature ONLINE SUBMITTAL Date 12/21/2019
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. It Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report may 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 Sensitive
Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas it they are subsequently discovered.This
document will serve as your Service Provider letter as required by Resolution and Order 19-05, 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 19-05,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 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
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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