Report (24) Clean Water Services File Number
C1eanWatee\' Services 17-003145
Sensitive Area Pre-Screening Site Assessment
1. Jurisdiction: Tigard
2. Property Information (example 1 S234AB01400) 3. Owner Information
Tax lot ID(s): Name: RANDY OLLISON
2S102BC06000 Company: CLASSIC RANCH LLC
Address: 3439 SW SCHOLLS FERRY RD
Site Address: 10540 SW PATHFINDER WAY City, State,Zip: PORTLAND,OR,97221
City, State, Zip: TIGARD,OR,97223 Phone/Fax: 5035156706
Nearest Cross Street: SW 107 CT,TIGARD,OREGON E-Mail: classicranch@gmail.com
4. Development Activity(check all that apply) 5. Applicant Information
• Addition to Single Family Residence(rooms,deck,garage) Name: Tuan Vu
❑ Lot Line Adjustment ❑ Minor Land Partition Company: Propel Studio Architecture
U Residential Condominium U Commercial Condominium Address: 5229 NE Martin Luther King Jr,Suite#101
❑ Residential Subdivision ❑ Commercial Subdivision
1:3Single Lot Commercial U Multi Lot Commercial City, State,Zip: Portland,OR,97212
Other Phone/Fax: 5415791193
An dettached 500sf garage accessory structure E-Mail: tuan@propelstudio.com
6. Will the project involve any off-site work? ❑Yes kj No U 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 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 Tuan Vu Print/Type Title
ONLINE SUBMITTAL Date 9/27/2017
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.
U 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 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
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 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 10/2/17
2550 SW Hillsboro Highway • Hillsboro,Oregon 97123 • Phone:(503)681-5100 • Fax:(503)681-4439 • www.cleanwaterservices.org