Fillable PIMA COUNTY FACILITY IMPACT PERMIT APPLICATION (Pima County Government)

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PIMA COUNTY FACILITY IMPACT PERMIT APPLICATION (Pima County Government)

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1/9/2019
PIMA COUNTY FACILITY IMPACT PERMIT APPLICATION
PIMA COUNTY REGIONAL FLOOD CONTROL DISTRICT
201 North Stone Avenue, 9
TH
FLOOR
TUCSON, ARIZONA 85701-1207
(520) 724-4600
THIS PERMIT APPLIES TO 4 TYPES OF ACTIVITIES WITHIN DISTRICT FACILITIES
TIER 1 – TEMPORARY IMPACT WITH MINIMAL DISTURBANCE
TIER 2 – LONG-TERM OR PERMANENT IMPACT WITH MINIMAL DISTURBANCE
TIER 3 – LIMITED DISTURBANCE
TIER 4 – DISTURBANCE OF A FACILITY
A LIST OF MATERIALS TO BE SUBMITTED WITH THIS APPLICATION FOR EACH TIER IS AVAILABLE ON THE DISTRICT
WEBSITE. A SITE PLAN IS REQUIRED FOR ALL ACTIVITIES.
IF YOU ARE UNCERTAIN WHICH TIER PERTAINS TO THIS PROJECT, CONTACT THE FACILITY IMPACT PERMIT REVIEWER AT
(520)724-4600 FOR ASSISTANCE.
TO BE FILLED OUT BY APPLICANT (PLEASE PRINT CLEARLY):
DATE
TOWNSHIP
S
RANGE
E
SECTION
TAX CODE
APPLICANT (responsible organization)
APPLICANT E-MAIL ADDRESS
APPLICANT PHONE NUMBER
APPLICANT MAILING ADDRESS
CITY
ZIP
CONTACT NAME (if applicant is an organization
or if applicant designates another contact)
CONTACT E-MAIL ADDRESS
CONTACT PHONE NUMBER
PROJECT SITE ADDRESS, PARCEL CODE OR DESCRIPTION
CITY
ZIP
LEGAL DESCRIPTION OR OTHER IDENTIFYING LOCATION INFORMATION
DETAILED DESCRIPTION OF WORK
IF APPLICABLE, DEVELOPMENT SERVICES PERMIT RECORD NUMBER
ATTACHED DOCUMENTS (CHECK ALL THAT APPLY)
_____ SITE PLAN
_____ PROPERTY RIGHT
_____ PROOF OF INSURANCE
_____ RESTORATION PLAN
_____ COST ESTIMATE
_____ BOND
_____ CONSTRUCTION PLANS
_____ 404 CERTIFICATE OF COMPLIANCE
_____ 408 CERTIFICATE OF COMPLIANCE
_____ RIPARIAN HABITAT DISTURBANCE CALCULATION
_____ SWPP
_____ OTHER ______________________________________________________________________________________
By signing this application, the undersigned requests written authorization
pursuant and subject to the requirements
of FACILITY IMPACT PERMIT ORDINANCE, 2018-FC1 for the project described above. Undersigned
agrees to abide by all
c
onditions contained or referred to herein and to indemnify, defend, and hold harmless Pima County and the Flood
Control District and their agents from and against any and all suits, claims, or demands associated with this permit.
Undersigned acknowledges that this application constitutes permission for District staff
to inspect the project site
and activities during the term of this permit. Under
signed acknowledges that the District has provided information
regarding the application process.
APPLICANT SIGNATURE
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PIMA COUNTY FACILITY IMPACT PERMIT APPLICATION (Pima County Government)

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Completed 18 July 2020

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