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Will the proposed activity/structure present a threat or risk of pollution, obstruction or interference <br />with regard to any primary or secondary intermittent stream, lake, pond, wetland, watercourse, <br />waterwork or drainage swale? If so, describe the threat or risk (attach additional sheets if <br />necessary): <br />Describe all measures the applicant will take to ensure that the proposed activity/structure will not <br />pollute, obstruct or interfere with any primary or secondary intermittent stream, lake, pond, wetland, <br />watercourse, waterwork or drainage swale (attach additional sheets ifnecessary): <br />NOTE: The town may require additional information from the applicant in order to process <br />and evaluate the application, including maps, drawings or plans. Additionally, the activity for which <br />a permit is sought may also be subject to regulation by Clear Creek County or some other <br />jurisdiction. Applicants should contact, at a minimum, the Clear Creek County Site Development <br />Department before undertaking any work or activity. <br />By signing this application, the applicant acknowledges and certifies that all information <br />contained herein, inclusive of maps and attachments, is in all respects true and accurate to the best <br />of his or her information and belief, and that false, incorrect or misleading information may result <br />in the denial or revocation of an exemption. The applicant also acknowledges that a site visit by <br />representatives of the town may be necessary as part of the application process. <br />No application will be accepted or processed unless it is complete and all fees have been <br />paid. In the event the town must retain outside professional services to process or evaluate an <br />application, or to inspect an activity or facility, the applicant shall bear the cost(s) for same, inclusive <br />of engineering and legal fees, in addition to the base application fee. A deposit to cover the <br />reasonable anticipated cost(s) for inspections and/or outside consultants may be required at time of <br />application. The applicant further agrees by submitting this application to abide by all ordinances, <br />regulations, terms and conditions applicable to any exemption or permit issued hereunder. <br />Applicant(s) <br />Signature <br />Printed name <br />DAClient Files\Georgetown\Forms\Watershed exemption application.wpd (2000) <br />2 of 2 <br />