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HomeMy WebLinkAboutApplication.pdfGarfield County �o munityy Development Department 108 8th Street, Suite 401 1014 Glenwood Springs, CO 81601 GARFiEL.() COUNTY X970) 945-8212 ",,1MIUNITY DEW LONK'Www.garfield-countv.com ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION Property Owner: Bureau Land Management Phone: (970) 876-9000 Mailing Address: 2300 Riverfront Rd, Silt, CO X New Installation • Alteration • Repair WASTE TYPE Contractor: WPX Energy 285-9377 Mailing Address: PO Box 370, Parachute, CO 81635 X Dwelling • Transient Use • Comm/Industrial Engineer: David Fox ■ Non -Domestic • Other Describe (970) 250-5505 Mailing Address: PO Box 370, Parachute, CO 81635 PROJECT NAME AND LOCATION INVOLVED PARTIES Property Owner: Bureau Land Management Phone: (970) 876-9000 Mailing Address: 2300 Riverfront Rd, Silt, CO Phone: (970) Contractor: WPX Energy 285-9377 Mailing Address: PO Box 370, Parachute, CO 81635 Engineer: David Fox Phone: (970) 250-5505 Mailing Address: PO Box 370, Parachute, CO 81635 PROJECT NAME AND LOCATION Job Address: DOE 2-W-27 - See the attached plat for description Assessor's Parcel Number: Building or Service Type: Distance to Nearest Community Was an effort made to 217322200951 Sub. house Lot Block Temporary office & #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 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 1st Ground water table NA Percent Ground Slope NA Final Disposal by 0 Absorption trench, Bed or Pit 0 Underground Dispersal 0 Above Ground Dispersal ❑ Evapotranspiration 0 Wastewater Pond 0 Sand Filter X Other Hauled to Down Valley Waste for their disposal Water Source & Type 0 Well 0 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. I 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 readrrd nderstand the Notice and Certification above as well as have provided the required informa i6n hi . h is correct and accurate to the best of my knowledge. Property Owner Print and Sign ©i/ c/' Date OFFICIAL USE ONLY Special Conditions: Permit Fee: I2, by Perk Fee:Total �a Fees: 123.00 Fees Paid: I23.o° Building Permit .__.---. Permit: 561 r - 33 Issue te: 1- X2-14 Balance Due: BLDG DIV: q — r# _, £ APPROVAL DATE • 41734nv) ✓ 30SO4'msgq. , -,2 � 5-0 0 ƒ\/.2 o .@ /§\3 ° 4-,.., $0 /\0 o § o E\22 xo> (0ta) E o c > 03 CD 0 a ® >, 0- m c 3 0 °°_c oo $ E =¥sa c . 2�\\ /.E o=a) ui % y . a7 =ee)— 0 Cr) 0-a00 \./_. - ) f E \=L ƒR $c § e c ®:»°a f \ c 0 0 G(0o=I (~ E -o %ns 7EE&%8� ui\§\ �$ƒ/®E% 77/\§ o= 5 8 2 ,-LJ 2 I' G E \\°°»as 0) 0.0 sGE/@5= c a °k$\°f/ \ \E� c o m a@ 5 # 0±& G 2m.\§2� >nn o ƒ§7f.0Sw °%/7/ /,k/ /\\ / ƒ�f2 \. / ±5 c. O. E =0)X 0) a -c"0 \fƒ\®/ƒ ®®2/§ /0°2-®t Qf°�2 J 7\(00 /22ƒk 2/sE'S± 3/rti 2.0 C c.E 2 a)- n c e��o\,# GPo— cl ƒf»k2�o ��R�fa k ®0 0— o o *= n m H a�7�//\ \0u— 0) 5 2 b_ .g 2, o %2—E�y Gm�2=? Uiii ®k�u��as \\�\0 0> of/>\ -cmy=\ \c66° k�c0\IEo\/ff- m\(0 721 ff%f/ E// % / o.E/ • ® kk f=¥00 § c t /@0 c2 2%Lƒ§ (j)\ $ 5 0 mm E c 0\6=co\ (0 =fe`7 c 0 '- » E£>o �IIl P%1'1/1011411ifi 11WiiK iCilkititlll'i 11111 Reeeption4; 818004 02/27/2012 12:10:10 PM Jean Atberioo 1 or 2 Rao Fee:$16.00 Coo Feal0.00 6RRFIELO 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; ?. 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 Attorney -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. v 1111hN'iI'IAdiIYNU:Nr+tPNtlifF K IMitUl1411.11.I1l111 R.etlona: 015004 02127/2012 11:18;10 PM len Rlb.rleo 2 0! 2 Reo Fee:S1S.00 Doc Fee:0,00 ORRFIELD 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 attomey this tst day of January, 2012. WPX .«t e■, RO ..•_- c TAIN, LLC By. Its.' ice Pr ident ACKNOWLEDGMENT STATE OF OKLAHOMA ) ) ss. COUNTY OF TULSA ) BEFORE ME, the undersigned authority, a Notary Public in and for said County and State, on this day personally appeared, Jeny D. Barnes personally known to me to be the Vice President of WPX Energy Rocky Mountain, LLC a Delaware limited liability company, who acknowledged to me 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, theb) I day of3anuary; 2012. FebeLt Sy My Commission Expires: 2. NotaryPu,tic f After Recordation Please Return To: WPX Energy Rocky Mountian, LLC Attn: Land Dept. PC) Box 370 Parachute, CO 81635 2