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CLEAR CREEK COUNTY SITE DEVELOPMENT DEPARTMENT <br />Post Office Box 2000 <br />Georgetown, Colorado 80444 <br />(303) 679-2421 <br />EXCAVATION PERMIT APPLICATION <br />OWNER(S) <br />HOMEPHONE WORK PHONE <br />MAILING ADDRESS <br />CITY STATE ZIP _ <br />APPLICANT(S) <br />(If different from owner -*also must submit Landowner Authorization Form) <br />HOME PHONE WORK PHONE <br />MAILING ADDRESS <br />CITY STATE ZIP <br />PROPERTY ADDRESS(ES) <br />PARCEL #'S <br />LEGAL DESCRIPTION OF PROPERTY <br />1/4 Section.& Section-Township-Range, Mining Claim Name& MS# or Subdivision-Lot-Block <br />DESCRIPTION OF PROPOSED USE <br />? I certify that the information I have provided is true and correct to the best of my knowledge. <br />? I have read, understand, and will comply with the above information and attached documentation. <br />? Any and all changes to the proposed excavation require notification of the Site Development Department. <br />? I will allow the Site Development Department staff to go onto my property in order to process this request. <br />Owner / Applicant <br />Date <br />FEE PAID DATE PAID RECEIPT # RECD BY <br />Rev. 8/24/07 <br />