HomeMy WebLinkAboutApplication.pdfilECEIVE'
Garfield :County
GARFIELD COUNTY
Community Dever iMplp 4) t1
108 8th Street, Suite 401
Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
X New Installation
0 Alteration
0 Repair
WASTE TYPE
X Dwelling
0 Other Describe
0 Transient Use
0 Comm/Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Youberg Beaver Creek Ranch
Phone: (716)
622-4212
Mailing Address: 215 S 10th Street, SAC City IA 50583-2137
Contractor: WPX Energy
Phone:
(970) 285-9377
Mailing Address: PO Box 370, Parachute, CO 81635
Fox
Phone:
(970)
Engineer: David
250-5505
Mailing Address: PO Box 370, Parachute, CO 81635
description
PROJECT NAME AND LOCATION
Job Address: RU 42-7 - See the attached plat for
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
240307300001 Sub.
Lot
Block
Temporary office & house
#Bedrooms:
2
Garbage Grinder No
Sewer System:
connect to the Community
NA
Sewer System:
NA
Type of OWTS
0 Septic Tank
0 Aeration Plant
X Vault
0 Vault Privy
1 0 Composting Toilet
❑ Recycling, Potable Use
0 Recycling
0 Pit Privy
0 Incineration Toilet
❑ Chemical Toilet
X Other
Hauled to Down Valley Waste for their disposal
Ground Conditions
Depth to lst Ground water table
NA
I Percent Ground Slope
NA
Final Disposal by
0 Absorption trench, Bed or Pit
0 Underground
Dispersal
Sand
0 Above Ground Dispersal
❑ Evapotranspiration
0 Wastewater
Pond
{ 0
Filter
X Other Hauled to Down Valley Waste for their disposal
Water Source & Type
0 Well
❑ Spring
0 Stream or Creek
0 Cistern
X Community Water System Name
Down Valley Septic and Waste
Effluent
Will Effluent be discharged directly into waters of the State? 0 Yes X No
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may be required by the local health department to be
made and furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of health in evaluating the same for purposes of issuing the permit applied for herein.
further understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and nderstand the Notice and Certification above as well as
have provided the required informatio
Property Owner Print and Sign
is correct and accurate to the best of my knowledge.
Dat
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
00 \P
Perk Fee:
rbc
NV I Fees: 00
tas.--'
Fees Paid:
$13 .��
I D3.
Building Permit
Septic Permit:
Issue Date:
— —14
Balance Due:
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101 FYrallIIUiN,V114111NrPIi� h+dt' 41�'h4+�41it,INi �I111
0212712011p2.10:i0DPM Jaen Albertoo
1 of 2 Reo Fee:$18.00 Doo Fee10.00 ORRFIELD COUNTY CO
LIMITED POWER OF ATTORNEY
WPX ENERGY ROCKY MOUNTAIN, LLC ("Company") a Delaware limited
liability company, having its principal place of business in the City of Tulsa, County of Tulsa,
State of Oklahoma, does hereby make, constitute and appoint Bryan S. Hotard with the full
authority hereinafter provided, the true and lawful Attorney -in -Fact of the Company, authorized
and empowered on behalf of the Company and in the Company's name, and for the sole and
exclusive benefit of the Company and not on behalf of any other person, corporation or
association, in whole or in part, to enter into, execute, deliver, file and accept all instruments and
documents affecting the real property or real estate rights of the Company as more specifically
set forth below: :
1. Applications and documentation associated with Garfield County or Rio Blanco
permitting requirements for including, but not limited to, Independent Sewage Disposal
Systems, Small Temporary Employee Housing, Major Impact Reviews, Limited Impact
Reviews, Oil and Gas well permitting, Driveway Access, County Road Maintenance,
Temporary Living Quarters, Temporary Use Permits, Surface Use Permits, Surface Use
Licenses, Utilities, Snow Removal and Private Construction of County Roads;
2. Agreements and other documentation that grant easements, rights of way, licenses, or
permits to Company and also instruments where the Company grants such rights to
others;
3. Agreements that assign easements, rights of way, licenses, permits or surface leases in
connection with the Company's operations;
4. Releases and Partial Releases of easements and rights of way;
5. Agreements allowing encroachments onto easements and rights of way owned by
Company and landowner instruments and conveyances on others easements;
6. Agreements subordinating mortgage rights to easement or lease ;
7. Agreements relating to the modification and relocation of Company facilities;
8. Rental or lease agreements for surface use or other surface use agreements and all notices
related to the pipeline agreements;
9. Agreements for the purchase or sale of real property and for the lease of real property for
residential or commercial purposes or otherwise in connection with the Company's
operations;
10. Agreements to obtain water services, electrical, gas or oil services or the provision of
other utility services utilized by Company's facilities;
11. Agreements modifying, amending, renewing, extending, ratifying forfeiting, canceling
and terminating any and all of the aforementioned types of instruments and documents.
WPX ENERGY ROCKY MOUNTAIN, LLC hereby declares that each and every
act, matter and thing which shall be given, made and done by Bryan S. Hotard in connection with
the exercise of any or all of the aforesaid powers shall be as good, valid and effectual to all
intents and purposes as if the same had been given, made and done by WPX Energy Rocky
Mountain, LLC in its limited liability company presence and it hereby ratifies whatsoever
Attomey-in-Fact shall lawfully do or cause to be done by virtue hereof. This Limited Power of
Attorney shall remain in full force and effect until terminated by Company.
Y
11111 rel'UIiti iliac finldD'Nft IONAth I' .i'41I III
Reotptiona; 615009
02121/2012 1210:10 PM Jaen Alberto*
2 of 2 Rea Fee:S10.00 baa Foe:0,0D GARFIELD COUNTY CO
IN WITNESS WHEREOF, WPX Energy Rocky Mountain, LLC has caused this
Limited Power of Attorney to be signed by one of its Vice Presidents, duly authorized by its
Management Committee to grant powers of attorney this In day of January, 2012.
STATE OF OKLAHOMA
) ss.
COUNTY OF TULSA
ACKNOWLEDGMENT
BEFORE ME, the undersigned authority, a Notary Public in and for said County and State,
on this day personally appeared, Jerry D. Barnes personally known to me to be the Vice President of
WPX Energy Rocky Mountain, LLC a Delaware limited liability company, who acknowledged tome
that he has executed the above LIMITED POWER. OF ATTORNEY authorized by Company's
Management Committee. �/
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notary seal, the701- 1
day of4anxety 2012.
Fel&'la.Yy
Notary Public
My Commission Expires: 2, — 25 2 0114
After Recordation Please Return To:
WPX Energy Rocky Mountian, LLC
Attn: Land Dept.
PO Box 370
Parachute, CO 81635
2