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CleanWater�` Services
SENSITIVE AREA PRE-SCREENING SITE ASSESSMENT
Clean Water Services File Number 20-001046
1. Jurisdiction; Tigard
2. Property Information(example: 1S234AB01400) 3. Owner Information
V LD
Tax lot ID(s): Name: Troy VanRiper
2S114AB04400 Company:
Address: 9310 SW Millen Dr. APR 2 0 2020
OR Site Address: 9310 SW Millen Drive City,State,Zip: Tigard, OR,97224 CITY OF TIGARD
City, State,Zip: Tigard, OR, 97224 Phone/fax: 5035474044 BUILDING DIVISION
Nearest cross street: 93RD Email: vanriper4@yahoo.com
4. Development Activity(check all that apply) 4. Applicant Information
jjjj Addition to single family residence(rooms, deck,garage) Name; Troy VanRiper
❑ Lot line adjustment 0 Minor land partition Company:
❑ Residential condominium D Commercial condominium Address: 9310 SW Millen Dr.
ElResidential subdivision 0 Commercial subdivision City, State,Zip: Tigard, OR, 97224
❑ Single lot commercial 0 Multi lot commercial Phone/fax: 5035474044
Other Email: vanriper4@yahoo.com
6. Will the project involve any off-site work? ['Yes 0 No ❑Unknown
Location and description of off-site work:
7. Additional comments or information that may be needed to understand your project:
I don't have the ability to scan my site plan currently but I could take a picture and email it if needed.
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 Troy VanRiper Print/type title
Signature ONLINE SUBMITTAL Date 3/31/2020
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.
❑ 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 19-5,Section
3.02.1,as amended by Resolution and Order 19-22.All required permits and approvals must be obtained and completed under applicable
local, State and federal law.
J�y"l 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 19-5,Section 3.02.1,as amended by Resolution and Order 19-22.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 4/14/2020
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 2/2020
Main Office • 2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • p: 503.681.3600 f: 503.681.3603 • cleanwaterservices.org