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HomeMy WebLinkAboutApplication.pdfGarfield County Community Development Department 108 8th Street, Suite 401 N6V 1 ty 1p14 Glenwood Springs, CO 81601 (970) 945-8212 GA�r1�O .0 CQu i www.garfield-county.com ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) PERMIT APPLICATION TYPE OF CONSTRUCTION Property Owner: Puckett Land Company Phone: (303) 763-1003 Mailing Address: 5406 S Quebec Street, Suite 250, Greenwood Village, CO 80111 X New Installation • Alteration ■ Repair WASTE TYPE Engineer: David Fox Phone: (970) 250-5505 Mailing Address: PO Box 370, Parachute, CO 81635 PROJECT NAME AND LOCATION X Dwelling • Transient Use • Comm/Industrial • Non -Domestic ■ Other Describe 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 INVOLVED PARTIES Property Owner: Puckett Land Company Phone: (303) 763-1003 Mailing Address: 5406 S Quebec Street, Suite 250, Greenwood Village, CO 80111 Contractor: WPX Energy Phone: (970) 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: GM 11-28 - See the attached plat for description Assessor's Parcel Number: 217129100005 Sub. Lot Block Building or Service Type: Temporary office & house #Bedrooms: 2 Garbage Grinder No Distance to Nearest Community Sewer System: NA Was an effort made to connect to the Community 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. 1 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. hereby acknowledge that I have read and understand the Notice and Certification above as well as have provided the required infor n which is correct and accurate to the best of my knowledge. Property Owner Print and Sign // aS �®i/ Da e OFFICIAL USE ONLY •� 23 • b. Special Conditions: Permit Fee: 123.60 Perk Fee: K,(oL Total Fees: 123 . Do Fees Paid: 123. co Building Permit Septic Permit: SI T - 3 -o Issue Date: It lb" b- III - Balance Due: I BLDG DIV: '`lk 1(-i 0- 14 APPROVAL DATE ) / 3DS 3L{ II -1 0'14 00 r cso 5: 0 ± os a0% / /k$6 °f0 E To 2 o q o .E 0 >7 o .> 0 E�.c> 0 a) 0_ y co c O co n = o $ ° 0 -c = _ .e > O %\a o o / \ E/5 o=ao� y t g a o =�./3 03 0) _c c �7 0% /G=k E f k ƒc°o 2 / co 2 E 55>°a -2coR 1-Tf1o=I / ± E 73 \ loc%%>w oaf)§( �kƒ%§B2 §k\c� e3ok\ 0\01SE k\\�2a \6/kf \/°o¢b0 ok£2= / 7i-/�» \W$/� m� _ =�4- om .\%tom » e \ § V f = 0 % $ f / % k o '5 ^ _ ° LV .E q Gn c� /� % »� 0 � � -.--, E =Qx=/§/ 0_c7� 4. 7/2$0)» \/mD/ moo §-/// %02»° / 0 \3fi/0 02/2ƒ c/aE'S$ ±•a30®tea.cg2G-n %R*o- --6 ' i-ij- -2c / �(13 /\® \�\w$e • cG p\A%\7®°fe?>£»=e\—e§ Eo n m / \ / ¥o m 0%a$\e»ef a'.22= \epe%o&$m$\ ° ^°?m_ 2 =m=/ \% #\® ko E�0502/c\>,\0 k\_a© as �ck°®�3/E\\\f O@E3n= //ƒE\ oE% -e- E E- a3a3 0 k c 0 \ 0 0 11111 ylJ'tlftliN Mu tilt 11. 1411114 4M'M1+,4191.11.111III 0212 /2012 12.110310aPM Joe0 01111,T190._ 1 of 2 14o FBO:S10.00 Coo F.ee0.0SRRFIELO COUNTY CO LIMITED POWER OF ATTORNEY KTX 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 Attomey-hi-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 Ibat 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 al] 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. Y tri,I Ml«1MUMPECio-YCIMM 10,1114 IIIA ?PAM Aa oe weRo ie. FIF10 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 ofJanuary, 2012. WPX _.ata, RO a AIN, LLC By mes Its:/ ice Pr• 'dent 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, 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 to me that he has executed the above LIMITED POWER OF ATTORNEY authorized by Company's Management Committee. �/ 114 WITNESS WHEREOF, I have hereunto set my hand and affixed my notary seal, theZ 1N ! day of4anttaty 2012. February My Commission Expires: Notary Pu.lic 2. -23-2o124 After Recordation Please Return To: WPX Energy Rocky Mountian, LLC Attn: Land Dept. PO Box 370 Parachute, CO 81635 2