Pre-Screen Form

In order to determine if the proposed activity will require a Service Provider Letter, the applicant may apply for a Prescreening Site Assessment. If no Water Quality Sensitive Areas appear to exist on or within 200 feet of the site, then no further site assessment or service provider letter is required. See Environmental Review Permit Process.

If you would prefer, you can also print a PDF version of this form and mail it or fax it to us.

Property Information

You must enter either a Tax Map & Lot ID (i.e. 1S234AB01400) or Site Address, but you do not have to enter both.

Tax lot ID(s):
Site Address:
City, State, Zip:
Nearest Cross Street:

In which jurisdiction would you get permits for this project?

Owner Information

Name:
Company:
Address:
City, State, Zip:
Phone/Fax:
E-Mail:

Copy from Property Information

Applicant Information

Name:
Company:
Title:
Address:
City, State, Zip:
Phone/Fax:
E-Mail:

Copy from Owner Information

Development Activity

Check all that apply

Addition to Single Family Residence (rooms, deck, garage)
Lot Line Adjustment	Minor Land Partition
Residential Condominium	Commercial Condominium
Residential Subdivision	Commercial Subdivision
Single Lot Commercial	Multi Lot Commercial

Other:

Off-site Work

Will the project involve any off-site work?

No Yes I'm not sure

Location and description of off-site work

Site Plan

Would you like to submit a site plan?

No, thank you. Yes, please!

Please choose a file below to add it to your pre-screen submission request. We accept files in PDF format, but will try to load others. Your file must be no larger than 8MB. If we are unable to load your site plan, you may be required to submit it via fax or mail.

Additional Comments

Additional comments or information that may be needed to understand your project

Submit

By submitting 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.

Additionally, 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.

Entries missing a fax number will be mailed to the Applicant's postal address. Submittals returned by postal mail will take additional time beyond our five working day timeframe to reach the applicant.