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Millcreek Planning and Zoning 3330 South 1300 East Millcreek, Utah 84106 [PHONE REDACTED] GEOLOGICAL HAZARDS DISCLOSURE AND ACKNOWLEDGEMENT Disclose and Acknowledgement Regarding Development of Property Located within a Geological Hazards Special Study Area The undersigned (print hereby certify (ies) to be owner(s) of the real property described below, which is located within Salt Lake County, State of Utah Millcreek File or Permit Number Street Address: Parcel Number (required): Legal Description (attached): Acknowledgements: 1. The real property described above is either partially or wholly located within a Geological Hazards Special Study Area as defined in Chapter 19.75, Geological Hazards Ordinance, in the Millcreek Code of Ordinances and consist of the following: Surface Fault Rupture Debris Flow High Liquefaction Potential Rock-Fall Path Moderate Liquefaction Potential Avalanche Path Landslide 2. This Geological Hazards Disclosure and Acknowledgement is filed in accordance with the Geological Hazards Ordinance (Chapter 19.75) requires: or does not require: ☐ a site-specific natural hazards study and report. If required by ordinance, a site specific geological hazards study and report has been prepared for the above described real property which addresses the nature of the hazards and their potential effect on the proposed development of the above described real property and the occupants thereof in terms of risk and potential damage. The report and conditions and requirements for development of the property are on file with Millcreek which is available for public inspection. ---PAGE BREAK--- Legal Description ---PAGE BREAK--- Millcreek Planning and Zoning 3330 South 1300 East Millcreek, Utah 84106 [PHONE REDACTED] PROPERTY OWNER’S AFFIDAVIT (Owner of the Real Property) STATE OF UTAH } } ss COUNTY OF SALT LAKE } The foregoing instrument was acknowledged before me this day of by Notary Public Residing in: