HomeMy WebLinkAbout1.0 ApplicationGARFIELD COUNTY
Building and Planning Department
108 8th Street, Suite 401
Glenwood Springs, Colorado 81601
Telephone: (970) 945-8212 Facsimile: (970) 384-3470
www.clarfield-county.com
OCT 282011
5TEN ^ 11-1 l- Io4CP
Small Temporary Employee Housing
Administrative Checklist
GENERAL INFORMATION — Submit 1 paper & 1 CD copy of the completed application to Planning Department wgin 48 hours following
occupation
(To be completed by the Small Facility Operator — e.g. well pad operator)
Section/Township/Range Location of Housing Site: Sec 27-T7S-R96W Well Pad Number: SG 43-27
Tax Parcel Number for Parcel Containing Housing Site: 2409-341-00-131
GPS and/or Lat-Long Coordinates of Housing Facility Site (Often
included in APD): Lat:39.407953 Long: -108.088203
Zone District: Rural
Maximum Number of Occupants at
Permitted Site (e.g. well pad): less than 8
Cumulative Amount of Time (in Days) The Facility Will be
at Location: 60days
State or Federal Permitting Agency Overseeing Reclamation, Restoration
and Revegetation and Relevant Permit Number: COGCC 400083604
Date of Installation: October 27th, 2011
Date of Removal: December 27th, 2011
Name of Landowner: Bosely Spring Creek Ranch LLC
Street Address: PO Box 26
Telephone: (970)379-6669
Email:
City: Woody Creek
State: CO
Zip Code: 81656
Name of Operator's Compliance Officer: Williams Production RMT Company LLC Bryan S. Hotard
Street Address: PO Box 370
Telephone: 970-285-9377 ext
2754
Email:
Bryan. Hotardwilliam
s.com
City: Parachute
State: CO
Zip Code: 81635
Company 24 -Hour Emergency Contact: Williams Production RMT Company LLC Phone Number: 970-285-9377
This Administrative Checklist must be received by the Garfield County Planning Department
hours following occupancy of the Small Facility.
within 48
be delivered to
within 48 hours
Office and
receipt) or verified is
the Operator's
been received by
A copy of this completed Administrative Checklist and all associated submittals shall
the Garfield County Sheriffs Office and relevant Fire Protection District (if
applicable)
following occupancy of the Small Facility. Additionally, the Garfield County Sheriffs
relevant Fire Protection District (if applicable) must be notified in writing (return
email (return receipt) within 48 hours following removal of the Small Facility. It
responsibility to confirm and obtain verification that the Administrative Checklist has
1
Fire Suppression Requirements (Per Performance Standard LZ
"A water storage tank is required to provide water to the sprinkler system (if applicable) and initial
suppression activities. The size of the water tank shall be determined based on sprinkler
calculations and initial suppression demands. The relevant fire protection district shall be
responsible for determining the size of the water storage tank. If the Small Facility is not within a fire
protection district, the Operator shall provide at least 2500 gallons of water dedicated to initial fire
suppression which is accessible with a dry hydrant."
Required Size of water storage tank for sprinkler system and initial suppression
activities: 500BBL/ 21,000 gallons
A. Outline of Process. The Small Temporary Housing Facility(ies) Review process shall
consist of the following procedures as more fully outlined in Section 4-109 of Article IV of the
Unified Land Use Resolution of 2008.
1. Application to relevant protection districts and the Garfield County Sheriffs Office.
2. Application to the County
B. Review Process. Prior to submittal of any forms to the Planning Department, the applicant
shall submit all documents to the relevant fire protection district(s) and the Garfield County
Sheriff's Office. All forms shall be accurately completed, signed, dated and submitted to the
Garfield County Planning Department within 48 hours following occupation of the Small
Facility.
C. Submittal Requirements. The application submitted to the County shall contain the following
information:
i. A vicinity map indicating the section, township, and range of the subject lot and the location
of Small Facility within the subject lot and the Permitted Site; general relation to surrounding
public roads, private roads, adjacent utility systems, residential development, other actively
permitted Small, Minor and Major Facilities, natural drainage courses and municipalities within
one (1) mile of the proposed Small Facility; north arrow and scale; GPS coordinates and current
surface ownership of the subject lot. The vicinity map shall be presented on a USGS 7.5
minute series quadrangle at a scale of 1"=2000' or equivalent, with a topography depicted at a
minimum of 40' intervals.
ii. Surveyed layout of the proposed Small Facility within the surveyed boundaries of the
Permitted Site, including at a minimum: sewage and wastewater disposal, trash receptacles,
potable water storage, all other associated infrastructure and all other equipment located within the
Permitted Site. (See Section 4-502 (C )(3) for site plan definition)
Hi. Identification of the private and public roadways accessing each Small Facility.
Roadways shall be marked as open, gated, and/or locked (include combinations). Detailed
directions, with mileage, shall be given from the nearest town within Garfield County, nearest Garfield
County Sheriff's Office dispatch location and responsible fire district headquarters to each Small
Facility, along each roadway. .
iv. Name, address and phone number of surface owner of the subject lot.
v. Name, address and phone number, including a 24-hour emergency response
number of at least two persons responsible for Operator's emergency field operations;
contact numbers for local hospitals, emergency response, fire protection
2
districts, Garfield County Sheriffs Office, Life/Care Flight, and applicable regulatory
agencies; site safety/evacuation plan; and any other written response plan for
potential emergencies at the Permitted Site.
vi. Identification of the anticipated dates of installation and removal of the Small Facility.
The site plan shall include a notation of the total cumulative length of time (number of
days) that the Small Facility will be installed at the Permitted Site.
ELIGIBILITY
Requirement (Section 7-808 (D)(3) — All Requirements
Must be Satisfied to be Eligible as a Small Facility
Applicant
Planning
Department
Complies (Y/N)
Complies (Y/N)
The Small Facility and any associated infrastructure must
be completely contained within a state or federally
permitted parcel (such as a Colorado Oil and Gas
Conservation Commission (COGCC) approved oil/gas
well pad) in which reclamation and revegetation are
secured with the permitting agency (Permitted Site); and,
YES
The Small Facility is located at the Permitted Site for less
than a cumulative of one (1) year and at the end of the
utilization period, all structures, foundations and
associated infrastructure are completely removed; and,
YES
The Small Facility shall have an occupancy of eight (8) or
fewer people within a Permitted Site (e.g. well pad) who
are employees, contractors or sub-contractors of the
operator of the small facility and are needed for onsite
safety of the related commercial, industrial, extraction or
highway operation.
Temporary employee housing facilities that do not have
the three characteristics listed above, or consist wholly or
in part of Recreational Vehicles as defined above, are
subject to the administrative permit requirements or the
Major Impact Permit process, standards and
requirements contained in this document.
YES
3
Building Information (Per Unit)
Unit 1
Make: AmeriTech Building System
Serial Number or Unit ID Number:
30-3321
Manufacture Year: 2008
Size of Unit (Square Feet):
14X56
Unit 2
Make: ATCO Structures
Serial Number or Unit ID Number:
354085938
Manufacture Year: 2008
Size of Unit (Square Feet):
14X56
Unit 3
Make:
Serial Number or Unit ID Number:
Manufacture Year:
Size of Unit (Square Feet):
Unit 4
Make:
Serial Number or Unit ID Number:
Manufacture Year:
Size of Unit (Square Feet):
Unit 5
Make:
Serial Number or Unit ID Number:
Manufacture Year:
Size of Unit (Square Feet):
ISDS Permit
ISDS Permit Number: SEPT -9-11-2224
Signature of Operator' ompliance 4
Officer: 0-• 0
(By signing this form, verify that al formation provided in
the best of my knowledge)
Print Name: Bryan S. Hotard
this checklist is correct and accurate to
Title: Attorney -In -Fact
4
Eligibility, Submittal and Performance Standards Certification
Section 7-808(D)(3) - Small Temporary Employee Housing Facilities (Small Facility(ies))
in Article VII — Standards, requires the that the following performance standards be met
with each facility:
Small Facilities, in the nature of Factory Built Nonresidential Structures [as defined under
C.R.S. 24-32-3302(a)] but NOT recreational vehicles [as defined under C.R.S. 42-1-102
(61), including truck, truck tractor, motor home or camper trailer], may be utilized for
housing of workers on projects related to commercial, industrial, mineral extraction or
highway operations, pursuant to the standards for Small Facilities contained in sub-
section (2), below. Such facilities are not subject to Garfield County building and fire
codes (building code, fire code). However, Small Facilities are subject to all pertinent
state (i.e. electrical permits), federal permits and relevant fire protection district(s) code
requirements.
Small Facilities shall have all of the following basic characteristics:
A. The Small Facility and any associated infrastructure must be completely contained
within a state or federally permitted parcel (such as a Colorado Oil and Gas
Conservation Commission (COGCC) approved oil/gas well pad) in which reclamation
and revegetation are secured with the permitting agency (Permitted Site); and,
B. The Small Facility is located at the Permitted Site for less than a cumulative of one
(1) year and at the end of the utilization period, all structures, foundations and
associated infrastructure are completely removed; and,
C. The Small Facility shall have an occupancy of eight (8) or fewer people who are
employees, contractors or sub -contractors of the operator of the small facility and are
needed for onsite safety of the related commercial, industrial, extraction or highway
operation.
Temporary employee housing facilities that do not have the three characteristics listed
above, or consist wholly or in part of Recreational Vehicles as defined above, are subject
to the administrative permit requirements or the Major Impact permit process, standards
and requirements contained in this document.
The Small Facility shall adhere to the following Standards: All required submittals (as
outlined in (2), above) shall be submitted to the Planning Department within 48 hours
following occupation of the Small Facility. Enforcement shall be in accordance with this
Resolution. The Small Facility shall demonstrate and certify compliance with the following
standards:
A. Small Facility must comply with all applicable federal, state and local laws and
regulations.
B. The Small Facility shall NOT contain recreational vehicles as defined in Section 7-
808 (D).
5
C. In no case shall unsafe water be used for drinking nor shall raw sewage or
contaminated water be discharged on the ground surface. The operator shall
conduct monthly tests (or quarterly if an on-site disinfection system is installed) and
maintain records of stored potable water samples specific for coli form bacteria.
Any tests indicating coli form contamination must be disclosed to the Garfield
County Board of Health or designee within 72 hours from the time the
contaminated water was tested.
D. Each Small Facility shall be maintained in a clean, safe and sanitary condition, free
of weeds and refuse. Any hazardous or noxious materials that must be stored at
the Small Facility for operational or security reasons must be managed in
accordance with all applicable federal, state and local laws and regulations.
E. At least one thirty (30) gallon (4 cubic feet) wildlife -proof refuse container shall be
provided for each Factory Built Non -Residential Structure unit. Said container(s)
must be durable, washable, non-absorbent metal or plastic with tight -fitting lids.
F. Refuse shall be disposed of weekly, at a minimum. Operators must keep
appropriate records, to be provided to the County or any interested third party upon
request, to demonstrate that refuse is collected in a timely fashion and disposed of
at a licensed facility.
G. Outdoor food storage is prohibited.
H. Factory Built Non -Residential Structures equipped by the manufacturer with a fire
sprinkler system, fire detection system, and/or alarm system shall be inspected,
tested, and maintained in accordance with the requirements of the relevant fire
protection district(s) and the Colorado Division of Housing.
I. Single -station carbon monoxide alarms shall be placed in each Factory Built Non -
Residential Structure.
J. One (1) or more approved fire extinguisher(s) of a type suitable for flammable
liquids, combustible materials and electrical fires (Class ABC), or dry chemical,
shall be located in each Factory Built Non -Residential Structure and placed in
accordance with applicable fire protection district and/or Colorado Division of
Housing codes.
K. Domestic animals are prohibited at all Small Facilities.
L. A water storage tank is required to provide water to the sprinkler system (if
applicable) and initial suppression activities. The size of the water tank shall be
determined based on sprinkler calculations and initial suppression demands. The
relevant fire protection district shall be responsible for determining the size of the
water storage tank. If the Small Facility is not within a fire protection district, the
Operator shall provide at least 2500 gallons of water dedicated to initial fire
suppression which is accessible with a dry hydrant within each Permitted Site for a
Small Facility.
M. The operator shall document all emergency situations requiring action by any
government agency or fire protection district, in writing, and such documentation
shall be presented to the Planning Department within 24 hours of the occurrence.
N. All required Access Permits shall be obtained from the Garfield County Road and
Bridge Department or the Colorado Department of Transportation.
6
O. The Garfield County Sheriff's Office and relevant fire protection district(s) shall be
notified and provided with all documentation as outlined in these regulations, within
48 hours following occupation of each Small Facility. In addition, the Garfield
County Sheriffs Office and relevant fire protection district(s) shall be notified either
by hard -copy or electronically within 48 hours following removal of all Small
Facilities. The Planning Department shall be copied on all such notification,
whether hard copy or electronic.
P. The Operator shall maintain records identifying workers, whether employees,
contractors or sub -contractors, and document the dates that each worker is housed
at the Small Facility. Such records shall be provided to the County or any additional
third party upon request.
Q. The Operator shall obtain a certification inspection conducted by a third -party
Professional Engineer Licensed in the State of Colorado. The certification shall
verify that at the time of inspection the identified Small Facility meets or exceeds
the standards set forth in Article 7.808 D. 2. of the Garfield County Land Use Code
of 2008, as amended. This certification shall be on forms provided by the Garfield
County Planning Department. The certification shall be provided to the Garfield
County Planning Department within 48 hours following occupation of the Small
Facility.
R. The Operator shall accurately complete all required forms provided by the Garfield
County Planning Department identifying the location of the facility
(Section/Township/Range, relevant Tax Parcel Number, and GPS coordinates or
Latitude/Longitude coordinates); relevant zone district; maximum number of
occupants; cumulative amount of time (in days) that the Small Facility will be at the
specified location; identification of the State or Federal permitting agency
overseeing reclamation, rehabilitation and revegetation of the Permitted Site and
relevant permit number; date of installation; date of removal; name and contact
information of the landowner; name and contact information of the Operator's
Compliance Officer; 24-hour emergency contact information for the Operator;
building information (make, manufacture year, serial number, size (square feet));
signature and contact information of the Operator's Compliance Officer.
S. Wastewater Disposal:
1) Vault System: All vault systems shall be designed and installed to
accommodate the maximum number of persons (eight or less
individuals), who will inhabit the Small Facility. In addition, all vault
systems shall be equipped with an overflow alarm device. Vault
systems shall be designed to accommodate a minimum of 75 gallons
of wastewater per person per day. If a vault system is proposed or has
been approved, the Operator must:
a. Demonstrate that year-round vehicular access is available and
maintained for safe and regular access for sewage hauling vehicles.
b. Maintain all sewage disposal records including but not limited to trip
logs/reports and landfill receipts as public records, available to the County
and/or any other interested third party upon request.
c. (b) Individual Sewage Disposal System (ISDS): If an ISDS is
proposed, then it shall be designed, installed and operated to
accommodate the maximum number of persons who will inhabit the Small
7
Facility (eight or less individuals) and shall otherwise be permitted and
operated in accordance with the Garfield County ISDS regulations as
contained in BOCC Resolution Number 1994H-136.
I hereby attest that I am the designated Compliance Officer for the aforementioned
Small Temporary Employee Housing Facility(ies). I attest that I have read and
understand the standards to which the Facility(ies) shall be installed and
operated. I attest that the Facility(ies) will be constructed and maintained in
accordance with all applicable Garfield County, State of Colorado and Federal
regulations and standards. In addition, I attest that I have read and understand the
enforcement provisions as described in Article 12 of the Garfield County Unified
Land Use Resolution of 2008. Further, I understand that non-compliance with any
of the provisions as outlined in Article 7-808 (D) (3) of the Garfield County Unified
Land Use Resolution of 2008 shall be enforced in accordance with Article 12.
Signature of Operator's Compliance Officer:
Print Name: Bryan S. Hotard
Title: Attorney -In- Fact
Phone Number: 970-285-9377 ext 2754
Email: Bryan.Hotard(a�williams.com Bob.CaughlinAwilliams.com
I hereby attest that I am a Licensed Professional Engineer in the State of
Colorado. I attest that I have conducted a visual inspection of the Small Facility
identified in this Administrative Checklist, as installed, and, based on information
from that inspection I certify that the Small Facility complies with the standards
set forth in Article 7-808 (D) (3) of the Unified Land Use Resolution of 2008.
PE Certification Number
PE Stamp
See
Summary
Date of Inspection See Summary
Print Name and Title: David Fox of Fox
Engineering Solutions
Signature See Form
8
Inspection Report for:
Prepare for:
Location:
Conducted By:
Date Conducted:
Paragraph
Reference
Fox Engineering Solutions LLC
670 Canyon Creek Drive, Grand Junction, CO 81507
Ph: (970) 250-5505 / Fax: (626) 784-0667
Email: coloradofox@bresnan.net
SG 43-27 Well Pad - Small Temporary Employee Housing
Williams Production RMT Company
NE 1/4 SE 1/4 of Section 27, T7S, R96W, 6th P.M. Garfield County
David Fox, P.E.
October 27, 2011
Garfield County
Article 7-808(D)(3) Land Use Resolution 2008
Characteristic or Standard Description
3.a. Small Facilities, in the nature of Factory Built Nonresidential
Structures [as defined under C.R.S. 24-32-3302(a)) but NOT
recreational vehicles [as defined under C.R.S. 42-1-102 (61), including
truck, truck tractor, motor home or camper trailer), may be utilized
for housing of workers on projects related to commercial, industrial,
mineral extraction or highway operations, pursuant to the standards
for Small Facilities contained in subsection (2), below. Such facilities
are not subject to Garfield County building and fire codes (building
code, fire code). However, Small Facilities are subject to all pertinent
state (i.e. electrical permits), federal permits and relevant fire
protection district(s) code requirements.
3.a.(1)
3.a.(2)
3.a.(3)
The Small Facility and any associated infrastructure must be
completely contained within a state or federally permitted parcel
(such as a Colorado Oil and Gas Conservation Commission (COGCC)
approved oil/gas well pad) in which reclamation and revegetation
are secured with the permitting agency (Permitted Site); and,
The Small Facility is located at the Permitted Site for less than a
cumulative of one (1) year and at the end of the utilization period, all
structures, foundations and associated infrastructure are completely
removed: and.
The Small Facility shall have an occupancy of eight (8) or fewer
people who are employees, contractors or sub -contractors of the
operator of the small facility and are needed for onsite safety of the
related commercial, industrial, extraction or highway operation.
Page 1 of 5
Inspection Comments
Colorado Division of Housing certifications noted on
Driller's trailer, Unit ID. 30-3321 with FBNR
Certification No. 20533 manufactured by Ameritech
Building Systems on October 13, 2008; and
Company trailer, Unit ID. 354085938 with FBNR
Certification No. 19708 manufactured by ATCO
Structures on July 14, 2008. All other aspects not
subject to visual inspection and certification by third
party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
SG 43-27 Inspection Fox Engineering Solutions LLC
Williams Production RMT Company October 27, 2011
1
Small Facility must comply with all applicable federal, state and local
laws and regulations.
2 The Small Facility shall NOT contain recreational vehicles as defined
in Section 7-808 (D).
3 In no case shall unsafe water be used for drinking nor shall raw
sewage or contaminated water be discharged on the ground surface.
The operator shall conduct monthly tests (or quarterly if an on-site
disinfection system is installed) and maintain records of stored
potable water samples specific for coli form bacteria. Any tests
indicating coli form contamination must be disclosed to the Garfield
County Board of Health or designee within 72 hours from the time
the contaminated water was tested.
4 Each Small Facility shall be maintained in a clean, safe and sanitary
condition, free of weeds and refuse. Any hazardous or noxious
materials that must be stored at the Small Facility for operational or
security reasons must be managed in accordance with all applicable
federal, state and local laws and regulations.
5 At least one thirty (30) gallon (4 cubic feet) wildlife -proof refuse
container shall be provided for each Factory Built Non -Residential
Structure unit. Said container(s) must be durable, washable, non-
absorbent metal or plastic with tight -fitting lids.
6 Refuse shall be disposed of weekly, at a minimum. Operators must
keep appropriate records, to be provided to the County or any
interested third party upon request, to demonstrate that refuse is
collected in a timely fashion and disposed of at a licensed facility.
7 Outdoor food storage is prohibited.
8 Factory Built Non -Residential Structures equipped by the
manufacturer with a fire sprinkler system, fire detection system,
and/or alarm system shall be inspected, tested, and maintained in
accordance with the requirements of the relevant fire protection
district(s) and the Colorado Division of Housing.
9 Single -station carbon monoxide alarms shall be placed in each
Factory Built Non- Residential Structure.
10 One (1) or more approved fire extinguisher(s) of a type suitable for
flammable liquids, combustible materials and electrical fires (Class
ABC), or dry chemical, shall be located in each Factory Built Non -
Residential Structure and placed in accordance with applicable fire
protection district and/or Colorado Division of Housing codes.
Page 2 of 5
Not subject to visual inspection and certification by
third party Professional Engineer.
No recreational vehicles observed on site.
One potable water tanks of approximately 4000
gallons and one 4000 -gallon sewage holding tank
onsite. All tanks and piping located above ground.
No on-site disinfection systems installed.
Site appeared to be maintained in clean, safe and
sanitary condition, free of weeds and refuse.
One wildlife -proof trash recepacle with a capacity of
approximately 20 cubic yards each onsite. Individual
refuse containers in each office/housing structure.
Not subject to visual inspection and certification by
third party Professional Engineer.
No outdoor food storage observed on-site.
No active fire sprinkler systems observed in any of
the factory built non-residential structures. Smoke
detectors observed in all factory built non-
residential structures. Colorado Division of Housing
(CDH) compliance tags on all factory built non-
residential structures stating compliance with
nonresidental construction standards of the State of
Colorado.
Carbon monoxide detector located in all factory
built non-residential structure (FBNR).
Fire extinguishers observed in all structures.
SG 43-27 Inspection Fox Engineering Solutions LLC
Williams Production RMT Company October 27, 2011
11 Domestic animals are prohibited at all Small Facilities.
12 A water storage tank is required to provide water to the sprinkler
system (if applicable) and initial suppression activities. The size of the
water tank shall be determined based on sprinkler calculations and
initial suppression demands. The relevant fire protection district shall
be responsible for determining the size of the water storage tank. If
the Small Facility is not within a fire protection district, the Operator
shall provide at least 2500 gallons of water dedicated to initial fire
suppression which is accessible with a dry hydrant within each
Permitted Site for a Small Facility.
13 The operator shall document all emergency situations requiring
action by any government agency or fire protection district, in
writing, and such documentation shall be presented to the Planning
Department within 24 hours of the occurrence.
14 All required Access Permits shall be obtained from the Garfield
County Road and Bridge Department or the Colorado Department of
Transportation.
15 The Garfield County Sheriffs Office and relevant fire protection
district(s) shall be notified and provided with all documentation as
outlined in these regulations, within 48 hours following occupation of
each Small Facility. In addition, the Garfield County Sheriff's Office
and relevant fire protection district(s) shall be notified either by hard-
copy or electronically within 48 hours following removal of all Small
Facilities. The Planning Department shall be copied on all such
notification, whether hard copy or electronic.
16 The Operator shall maintain records identifying workers, whether
employees, contractors or sub -contractors, and document the dates
that each worker is housed at the Small Facility. Such records shall be
provided to the County or any additional third party upon request.
17 The Operator shall obtain a certification inspection conducted by a
third -party Professional Engineer Licensed in the State of Colorado.
The certification shall verify that at the time of inspection the
identified Small Facility meets or exceeds the standards set forth in
Article 7.808 D. 2. of the Garfield County Land Use Code of 2008, as
amended. This certification shall be on forms provided by the
Garfield County Planning Department. The certification shall be
provided to the Garfield County Planning Department within 48
hours following occupation of the Small Facility.
Page 3 of 5
No domestic animals observed on-site.
One potable aboveground water tank of
approximately 4000 gallons capacity on-site. Potable
water demand is estimated to be 300 gallons/day
gallons (4 individuals x 75 gpcd). Required fire
suppression demand is 2500 gallons. Total potable
and fire suppression volume required is estimated
to be 4000 gallons. Water supply appears adequate
with 4000 gallons of storage with refills scheduled at
5 -day intervals. Dry hydrant observed on water
tank.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
This inspection was conducted by a third -party
Professional Engineer licensed in Colorado and
certifies compliance only with applicable standards
set forth in Article 7.808 D. 3. of the Garfield County
Land Use Code of 2008, as amended, that are
subject to visual inspection.
SG 43-27 Inspection Fox Engineering Solutions LLC
Williams Production RMT Company October 27, 2011
18 The Operator shall accurately complete all required forms provided
by the Garfield County Planning Department identifying he location
of the facility (Section/Township/Range, relevant Tax Parcel Number,
and GPS coordinates or Latitude/Longitude coordinates); relevant
zone district; maximum number of occupants; cumulative amount of
time (in days) that the Small facility will be at the specified location;
identification of the State or Federal permitting agency overseeing
reclamation, rehabilitation and revegetation of the Permitted Site
and relevant permit number; date of installation; date of removal;
name and contact information of the landowner; name and contact
information of the Operator's Compliance Officer; 24-hour
emergency contact information for the Operator; building
information (make, manufacture year, serial number, size (square
feet)); signature and contact information of the Operator's
Compliance Officer.
19(a)
Vault System: All vault systems shall be designed and installed to
accommodate the maximum number of persons (eight or less
individuals), who will inhabit the Small Facility. In addition, all vault
systems shall be equipped with an overflow alarm device. Vault
systems shall be designed to accommodate a minimum of 75 gallons
of wastewater per person per day. If a vault system is proposed or
has been approved, the Operator must:
19(a)(1) Demonstrate that year-round vehicular access is available and
maintained for safe and regular access for sewage hauling vehicles.
19(a)(2)
19(b)
Maintain all sewage disposal records including but not limited to trip
logs/reports and landfill receipts as public records, available to the
County and/or any other interested third party upon request.
Individual Sewage Disposal System (ISDS): If an ISDS is Facility (eight
or less individuals) and shall otherwise be permitted and operated in
accordance with the Garfield County ISDS regulations as contained in
BOCC Resolution Number 1994H-136. proposed, then it shall be
designed, installed and operated to accommodate the maximum
number of persons who will inhabit the Small Facility (eight or less
individuals) and shall otherwise be permitted and operated in
accordance with the Garfield County ISDS regulations as contained in
BOCC Resolution Number 1994H-136.
Page 4 of 5
Not subject to visual inspection and certification by
third party Professional Engineer.
One aboveground sewage holding tank with 4000 -
gallon capacity on-site. Sewage flows estimated to
be 300 gallons/day (4 individuals x 75 gpcd).
Sewage holding tanks need to be emptied
approximately every 13.3 days (4000 gallons / 300
gallons per day). Wastewater vault equipped with
overflow alarm device.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
Not subject to visual inspection and certification by
third party Professional Engineer.
SG 43-27 lnspection Fox Engineering Solutions LLC
Williams Production RMT Company
October 27, 2011
I hereby attest that I am a Licensed Professional Engineer in the State of Colorado. 1 attest that I have conducted a
visual inspection of the Small Facility identified in this Administrative Checklist, as installed, and, based on
information from that inspection 1 certify that the Small Facility complies with the standards, subject to and
limited to visual inspections items as identified above; set forth in Article 7-808 (D) (3) of the Unified Land Use
Resolution of 2008, for Garfield County, Colorado.
PE Certification Number: No. 25420 (Colorado
Date of Inspection: October 27, 2011
Print Name and Titje 1 David J. Fox, Princ'pal Engineer
Signature: '•..- " i .� LX
Page 5 of 5
PE Stamp
GARFIELD COUNTY
BUILDING AND PLANNING DEPARTMENT
FEE SCHEDULE
Garfield County, pursuant to Board of County Commissioners ("Board") Resolution No.
98-09, has established a fee structure ("Base Fee") for the processing of each type of
subdivision and land use applications.
The Base Fee is an estimate of the average number of hours of staff time devoted to
an application, multiplied by an hourly rate for the personnel involved. The Board
recognized that the subdivision and land use application processing time will vary and
that an applicant should pay for the total cost of the review which may require
additional billing. Hourly rates based on the hourly salary, and fringe benefits costs of
the respective positions combined with an hourly overhead cost for the office will be
used to establish the actual cost of County staff time devoted to the review of a
particular project.
Actual staff time spent will be charged against the Base Fee. After the Base Fee has
been expended, the applicant will be billed based on actual staff hours accrued. Any
billing shall be paid in full prior to final consideration of any land use permit, zoning
amendment or subdivision plan. If an applicant has previously failed to pay application
fees as required, no new or additional applications will be accepted for processing until
the outstanding fees are paid.
Checks, including the appropriate Base Fee set forth below, must be submitted with
each land use application, and made payable to the Garfield County Treasurer.
Applications will not be accepted without the required application fee. Base Fees are
non-refundable in full, unless a written request for withdraw from the applicant is
submitted prior the initial review of the application materials.
Applications must include a Payment Agreement Form ("Agreement") set forth below.
The Agreement establishes the applicant as being responsible for payment of all costs
associated with processing the application. The Agreement must be signed by the
party responsible for payment and submitted with the application in order for it to be
accepted.
The following Base Fees shall be received by the County at the time of submittal of
any procedural application to which such fees relate. Such Base Fees shall be in
addition to and exclusive of any cost for publication or cost of consulting service
determined necessary by the Board for the consideration of any application or
additional County staff time or expense not covered by the Base Fee, which have not
otherwise been paid by the applicant to the County prior to final action upon the
application tendered to the County.
GARFIELD COUNTY BUILDING AND PLANNING DEPARTMENT
BASE FEES
TYPE OF LAND USE ACTION
Vacating Public Roads & Rights -of -Way
Sketch Plan
Preliminary Plan / Conservation Subdivision
Preliminary Plan Amendment
Final Plat
Final Plat Amendment / Correction Plat
Combined Preliminary Plan and Final Plat
Minor Exemption / Amendment
Major Exemption / Amendment
Rural Land Development Option Exemption / Amendment
General Administrative Permit
Floodplain Development Permit
Pipeline Development Plan / Amendment
Small Temporary Employee Housing
Minor Temporary Employee Housing
Limited Impact Review / Amendment
Major Impact Review / Amendment
Rezoning: Text Amendment
Rezoning: Zone District Amendment
Planned Unit Development (PUD) / Amendment
Comprehensive Plan Amendment
Variance
Interpretation
Takings Determination
Planning Staff Hourly Rate
• Planning Director
• Senior Planner
• Planning Technician
• Secretary
BASE FEE
$400
$325
$675 + application agency
review fees and outside
consultant review fees, as
authorized pursuant to the
Regulations, such as the
Colorado Geologic Survey
$325
$200
$100
$1,075
$300 / $300
$400 / $300
$400 / $300
$250
$400
$400 / $300
$50
$250
$400 / $300
$525 / $400
$300
$450
$500 / $300
$450
$250
$250
NO FEE
$50.50
$40.50
$33.75
$30.00
County Surveyor Review Fee (includes review of Amended Determined by Surveyor$
Plats, Final Plats, Exemption Plats)
$ 1 1 — Mylar Record i n g Fee st
$10 each additional page
Page 2
The following guidelines shall be used for the administration of the fee structure set
forth above:
1. All applications shall be submitted with a signed Agreement for Payment form set
forth below.
2. County staff shall keep accurate record of actual time required for the processing
of each land use application, zoning amendment, or subdivision application. Any
additional billing will occur commensurate with the additional costs incurred by
the County as a result of having to take more time that that covered by the base
fee.
3. Any billings shall be paid prior to final consideration of any land use permit,
zoning amendment, or subdivision plan. All additional costs shall be paid to the
execution of the written resolution confirming action on the application.
4. Final Plats, Amended or Corrected Plats, Exemption Plats or Permits will not be
recorded or issued until all fees have been paid.
5. In the event that the Board determines that special expertise is needed to assist
them in the review of a land use permit, zoning amendment, or subdivision
application, such costs will be borne by the applicant and paid prior to the final
consideration of the application. All additional costs shall be paid prior to the
execution of the written resolution confirming action on the application.
6. If an application involves multiple reviews, the Applicant shall be charged the
highest Base Fee listed above.
7. Types of "Procedures" not listed in the above chart will be charged at an hourly
rate based on the pertinent planning staff rate listed above.
8. The Planning Director shall establish appropriate guidelines for the collection of
Additional Billings as required.
Page 3
GARFIELD COUNTY BUILDING AND PLANNING DEPARTMENT
PAYMENT AGREEMENT FORM
(Shall be submitted with application)
GARFIELD COUNTY (hereinafter COUNTY) and Bosely Spring Creek Ranch LLC
Property Owner (hereinafter OWNER) agree as follows:
1. OWNER has submitted to COUNTY an application for
SG 43-27 pad location STEN &ISDS (hereinafter, THE PROJECT).
2. OWNER understands and agrees that Garfield County Resolution No. 98-09, as
amended, establishes a fee schedule for each type of subdivision or land use review
applications, and the guidelines for the administration of the fee structure.
3. OWNER and COUNTY agree that because of the size, nature or scope of the
proposed project, it is not possible at this time to ascertain the full extent of the costs
involved in processing the application. OWNER agrees to make payment of the Base Fee,
established for the PROJECT, and to thereafter permit additional costs to be billed to
OWNER. OWNER agrees to make additional payments upon notification by the COUNTY
when they are necessary as costs are incurred.
4. The Base Fee shall be in addition to and exclusive of any cost for publication or
cost of consulting service determined necessary by the Board of County Commissioners for
the consideration of an application or additional COUNTY staff time or expense not covered
by the Base Fee. If actual recorded costs exceed the initial Base Fee, OWNER shall pay
additional billings to COUNTY to reimburse the COUNTY for the processing of the
PROJECT mentioned above. OWNER acknowledges that all billing shall be paid prior to
the final consideration by the COUNTY of any land use permit, zoning amendment, or
subdivision plan.
PROPERTY OWNER (OR
ORIZED REPRESENTATIVE)
Bryan S. Hotard
Print Name
Mailing Address:
_./a a'f //
Date
Williams Production RMT Company LLC
PO Box 370, Parachute, CO 81635
Page 4
Prevail in
Winds
SCALE: 1" = 60'
DATE: 03-13-10
DRAWN BY: D.R.B.
Rev: 04-08-10 D.R.B.
Rev: 07-15-10 O.R.B.
F-3.2'IL
Et. 14.5'
Approx.
Toe of
Fill Slope
WILLIAMS PRODUCTION RMT COMPANY
PLAT #2_CONSTRUCTION LAYOUT FOR SG 43-27
SECTION 27, T7S, R96W, 6th P.M.
6
\ Existing
Pipeline
Existing
Fence/ine
PRDUC710N
EQUIPMENT AREA
Berm (150'x602 )
C-0.2'
Et. 17.9'
,.1140.
••
.• Rj L '�.
... 0'*G\STi ..r'9{- •
o;
• es'
•
• r =
• /.iia. I
• •
S °,..< A NDOF,�r.',0 •11
VEY �,.� .
OF CO'-. •••
1140 h°
C-7.2'1
El. 24.9'
•
•
••
•
•
Round Corners ------
Berm as Needed
Exist. Fence/ine
flare Pit
60'
Prop. SG 541-27
I GRADE Prop. SG 42-27
El. 17.7'—drop. SO 342-27
Exist SG 43-27
Exist SG 343— 7
Meth. Tank
Exist. SG 443-
Exist. SG 543-2
F-0.4'
El. 17.3'
1
O-
O_
EZ 17.8'
7.5'
7.5'
.5
15.1'
14.7'
Cut/Fill
Transition Line
8
F-4.5'
El. 13.2'
AnchorT
(T1'P•)
' '
J C-0.1' C 1�B
E/. /7.8' / /
Access Road
Elev. Ungraded Ground At Loc. Stake = 5017.7'
FINISHED GRADE ELEV. AT LOC. STAKE =,5017 7'
0
.:Sto.� 3+50
U
CO o
ti
Q. y
y y
ct
Sta. 2+60
1
CUTTING PIT
,roto/ P11 'Copocity
t7/2' of Freeboard
= 8,390 8b1s.
:Toto/ Pit Volume
=2,170Cu. Yds.
ryq'
Sto. 1+75
-C-8.9'
E/. 26.6'
Approx.
Top of
Cut Slope
Sta. 1+00
N1
Sta. 0+00
NOTE.
Fiore Pit is to
be located o min.
of 100' from the
Well Head.
N �
UINTAH ENCINEERINC & LAND SURVEYING
85 So. 200 East * Verne , Utah 84078 ' (485) 789-1017
scab;
PROPOSED LOCATION: I
R
96
W
.i'
5'04;'
Ij.
•
14(
5600 \`
=f�`e
ewe*
,
•
.T8S'
.f�
LEGEND:
r4\
E.XISTINGROAD
Uintah Engineering & Land Surveying
85 South 200 Cast Vernal, Utak 84078
(435) 789-1017 * FAX (435) 789-1813
oo.^r
WILLIAMS PRODUCTION RMT COMPANY
N SG 43-27
SECTION 27, T7S, R96W, 611i P.M.
TOPOGRAPHIC
MAPYEAR
0 12
It DAY
10
SCALE: ]"= 2000'1 DRAWN BY, Mi. ]REVISED: 00-00-004
5
PLAT
Bonuales, Gia
From: Bonuales, Gia
Sent: Friday, October 28, 2011 9:26 AM
To: 'jsears@garcosheriff.com'; 'Julie Taylor'
Cc: Reed, Gary
Subject: SG 43-27 Rig Move On Notification
Attachments: SG 43-27 Sheriff Letter & Map dated 10-28-11. pdf
I am notifying you on the attached pad location we will be commencing drilling operations in the next few days and
these operations will continue for approximately 60 days. At which time I will notify you of the removal of the Employee
housing.
This notification is per the GARCO Regulations for our pad located in Sec 27- T7S-R96W. Attached please find a map with
directions to the pad, a pad lay out and emergency contact information.
Should you have any questions please let me know.
{ It Bonclni(?
Land Data Technician 1
Williams Production RMT Company LLC
1058 County Road 215/P0 Box 370
Parachute, Co 81635
970.263.2746 -Office
970.216.8537 -Cell
970.285 -2047 -Fax
gia.bonuales@williams.com
1
October 28th, 2011
Garfield County Sheriff's Office
Emergency Operations
Attn: Jim Sears
108 8th Street
Glenwood Springs, CO 81601
Ph: 970-945-0453
RE: Emergency Response Notification Drilling
SG 43-27 pad
Dear Jim:
Williams®
Williams Production RMT Company LLC
1058 CR #215
P.O. Box 370
Parachute, CO 81635-0370
970/285-9377
970/285-9573 fax
This letter is to inform the Garfield County Sheriff's Department that Williams Production
RMT Company LLC will soon commence drilling operations on the above mentioned
drilling location. Williams will provide rig site housing accommodations for the duration
of the drilling operation approximately 60 days.
In accordance with Garfield County Planning and Zoning Regulations, the attached
documentation provides emergency response information and driving directions for the
Williams SG 43-27 pad.
Should you have any further questions or concerns regarding this notification, feel free to
contact me at (970)263-2754.
Sincerely,
Bryan S. Hotard
Field Land Team Lead-Piceance District
gb
Bonuales, Gia
From: Bonuales, Gia
Sent: Friday, October 28, 2011 926 AM
To: 'Rob Ferguson'; 'Julie Taylor'
Cc: Reed, Gary
Subject: SG 43-27 Rig Move On Notification
Attachments: SG 43-27 GVFPD Letter & Map dated 10-28-11.pdf
1 am notifying you on the attached pad location we will be commencing drilling operations in the next few days and
these operations will continue for approximately 60 days. At which time I will notify you of the removal of the Employee
housing.
This notification is per the GARCO Regulations for our pad located in Sec 27- T7S-R96W. Attached please find a map with
directions to the pad, a pad lay out and emergency contact information.
Should you have any questions please let me know.
,71fti ,i3onu icf3
Land Data Technician I
Williams Production RMT Company LLC
1058 County Road 215/PO Box 370
Parachute, Co 81635
970.263.2746 -Office
970.216.8537 -Cell
970.285 -2047 -Fax
gia.bonuales@williams.com
1
Whams®
Williams Production RMT Company LLC
1058 CR #215
PO. Box 370
Parachute, CO 81635-0370
970/285-9377
970/285-9573 fax
October 28th, 2011
Grand Valley Fire Protection District
Emergency Operations
Attn: Rob Ferguson
1777 S. Battlement Parkway
Parachute, CO 81635
Ph: 970-285-9119
RE: Emergency Response Notification Drilling Pad
SG 43-27 pad
Dear Rob:
This letter is to inform the Grand Valley Fire Protection District that Williams Production
RMT Company LLC will soon commence drilling operations on the above mentioned
drilling location. Williams will provide rig site housing accommodations for the duration
of the drilling operation approximately 60 days.
In accordance with Garfield County Planning and Zoning Regulations, the attached
documentation provides emergency response information and driving directions for the
Williams SG 43-27 pad.
Should you have any further questions or concerns regarding this notification, feel free to
contact me at (970)263-2754.
Sincerely,
Bryan S. Hotard
Field Land Team Lead-Piceance District
gb
X1I HIM 11111
00o0,r,) =
§o ;�r1IIIIIIIIIIIIII�
PL
1 1II11111111111111111111111111111111111111111111111111 ;
678744 07/22/2005 02 37P B1709 P200 M ALSDORF
1 of 1 R 6.00 D 0.00 GRRFIELD COUNTY CO
STATEMENT OF AUTHORITY
NAME OF ENTITY: The name of the entity to which this Statement relates is Bosely
Spring Creek Ranch LLC.
TYPE OF ENTITY: The entity is a Limited Liability Company formed under the laws of the
State of Colorado.
MAILING ADDRESS: The mailing address for the entity is P. O. Box 26, Woody Creek,
Colorado 81656,
AUTHORIZED PERSON: The names and positions of the person authorized to execute
instruments conveying, encumbering or otherwise affecting title to real property on behalf
of the entity are as follows:
Name Position
Mary Anne Bosely Manager
LIMITATIONS: None.
Dated this ist day of July , 2005.
STATE OF COLORADO )
) ss.
COUNTY OF GARFIELD )
The foregoing instrument was subscribed, sworn to and acknowledged before me
this 1st day of July , 2005, by Mary Anne Bosely as Manager of Bosely
Spring Creek Ranch LLC.
WITNESS my hand and official seal.
My Commission expires: 10/31/2007
Notary Public
A Y'r1:N RECON„INC lit:'TUR TO: SCIIr.YIt, HERS..' S 111:N'Ix"1'XH
302 82114'.'., St.:. O 111, Cfl h M'V000 S'PRINO'I, CO 0.111111
September 21", 2011
Mr. Fred Jarman, Director
Garfield County Building and
Planning Department
108 8th Street, 4'h Floor
Glenwood Springs. CO 81601
RE: SG 43-27, SG 13-35
Drilling Pad Locations,
Garfield County, Colorado
Dear Mr. Jarman:
This letter authorizes Williams Production RMT Company LLC to represent me in the
submittal and processing of the required Garfield County Small Temporary Employee
Rousing (STEH) and Individual Sewage Diaposal System (JSDS) permits on the above
drilling pad locations.
Sincerely,
Bo54Sc
Spring Creek
By:
Title:
td
ifRlIKRIt2aW p90W
EM4aW P*WMRh 1111
1 rR3REeie542Doo nIte.,,1U0
NNIY e0
LTMTED POWER OF ATTORNEY
WILLIAlriS PRODUCTION RMT COMPANY 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. Retard with the
Rill 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 fights of the Company including but not
limited to, the following described instnuuente and docimhents:
I. Applications and documentation associated with Garfield County or Rio Blanco
permitting requirements, 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 Quarter, Temporary Use Permits, Surface Use Permits, Surface Use
Licenses, Utilities, Snow Removal andPrivate 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 enttoachmmts onto easements and rights of way owned by
Company and landowner instruments and conveyances ea others easements;
6. Agreements subordinating easement or lease to mortgage rights;
7. Agreements misting 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 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;
1 I. Agreements modifying, amending, renewing, extending, rattying forfeiting, canceling
and terminating any and all of the aforementioned types of instruments and documents.
The Company hereby declares that each and every act, matter and thing which
shall be given, made and done by Bryan S. Retard in connection with 11m maniac of any or all
of the aforesaid powers shall be as good, valid snd effectual to all intents and purposes as if the
same had baa given, made and done by the Company in its limited liability company presence
and it hereby ratifies whatsoever Attorney -in -Fact shall lawfully do or cause to be done by 'MUG
hereof This Limited Power of Attorney shall remain in fiill fora and effect until terminated by
Company.
L
r'iraiM1am.\
Nsit IVINiMN41tll
nindMaeeo«• e teR
EOMfY d
IN WITNESS WHEREOF, the Company has caused this Limited Power of Attorney to
be signed by one of its Vice pmsidarts, duly authorized by its Management Committee to grant
powers of attorney this Ufday of July, 2011.
WIL e, MS 'i'ODU a iii♦COMPANY LLC
Ey:
Its:
D. Ba
ce Pits'+
es
nt
ACKNOWLEDGMENT
STATE OF OKLAHOMA )'
)as.
COUNTY OF TULSA
BEFORE MB, the undersigned authority, a Notary Public in and for said County end State,
on this day personally appeared, Jetty D. Games personally Totowa to me to be the Vice President of
WILLIAMS PRODUCTION RMT COMPANY LLC a Delaware limited liability company, who
acknowledged to me that he has executed the above LIMITED POWER OF ATTORNEY authorised
by Company's Management Committee.
114 WTTNBSS W HBRI3OF, I have baeunto set my hand and affixed my notary seal, the I I
day orJuly, 2011.
My Commission Diplom: 2. - 2.3 - 2o 14
AFTER RECORDATION PLEASF RFTURN TO
VNLLTAMS PRODUCTION CO RMT LLC
ATTN: LAND DEPT.
P.O. BOX 370
PARACHUTE, CO 81635
2
J
Project Address
Garfield County
Building & Planning Department
108 8th Street Suite 401
Glenwood Springs, CO 81601 -
Phone: (970)945-8212 Fax: (970)384-3470
Parcel No.
Permit NO. SEPT -9-11-2224
Permit Type: Septic Permit
Work Classification: New
Permit Status: Under Review
Issue Date: Not Issued
Expires: 01/01/2999
Subdivision
Section Township Range
1587 SG 43-27 (CR 300) RD
PARACHUTE, CO
240934100131
Owner Information
Address
BOSELY SPRING CREEK RANCH LL CO
PO BOX 26
Woody Creek CO 81656 -
Phone
CeII
Contractor(s)
Phone
Primary Contractor
Williams Production RMT (970)285-9377
Yes
Proposed Construction / Details
small temp emp hsg
FEES DUE
Fee
Septic Fee - New
Total:
Amount
$73.00
$73.00
Valuation:
Total Sq Feet:
$ 0.00
0
FEES PAID
Inv Total Paytype Amt Paid Amt Due
Inv # SEPT -9-11-21424
$ 73.00 Check # 30572378
$73.00
$ 0.00
Required Inspections:
For Inspections call : 1(888)868-5306
Inspection
IVR
See Permit Record
Building Department
Copy
Wednesday, September 28, 2011 2
GARFIELD COUNTY SEPTIC PERMIT APPLICATION
1088'"Street, Suite401, Glenwood Springs, CO 81601
Phone: 970-945-8212 / Fax: 970-384-3470 / Inspection Line: 970-384-5003
www. earl icld-county. com
1
Perk Gee:
Parcel No:(this information is available at the assessors office 970-945-9134)
2409-341-00-131
2
Septic P erm #• �f
Job Address: (if an address has not been assigned, please provide Cr,Hwy or Street Name & City) or legal description
SG 43-27 See the attached plat for description.
3
APPROVA DATE
Lot Size: Lot No: Block No: Subd/Exemption:
See Attached Survey Plat
4
Owner: (property owner)
Bosely Spring Creek
Ranch LLC
Mailing Address
PO Box 26
Woody Creek, CO 81656
Ph:
970-923-8999
Alt Ph:
5
Contractor:
Williams Production
RMT Company LLC
PO Box 370, Parachute, CO
81635
Ph:
970-285-9377 ext 2754
Alt Ph:
6
Engineer:
NIA
Mailing Address
Ph:
Alt Ph:
7
Permit Reauest For: (X 1 New Installation 1 ) Alteration ( 1 Reoair
8
Waste Type: (X ) Dwelling ( ) Tranient Use ( ) Commercial or Industrial ( ) Non- Domestic Wastes
( ) Other- Describe
9
Building Or Service Type:
Number of Bedrooms: 2 Garbage Grinder ( ) Yes (X )No
10
Source & Type of Water Supply: ( ) Well ( ) Spring ( ) Stream Or Creek ( ) Cistern
If supplied by COMMUNITY WATER, give name of supplier: Down Valley Septic and Waste
11
Distance to Nearest Community Sewer
Was there an effort to connect to the
System: _N/A
community System? N/A
YOUR INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT WILL NOT BE ISSUED WITH OUT A SITE PLAN
12
Ground Conditions:
Depth to 1st Ground Water Table N/A Percent Ground Slope N/A
13
Type of Individual Sewage System (ISDS) Proposed:
( ) Septic Tank ( )Aeration Plant ( X ) Vault ( ) Vault Privy ( )Composting Toilet
( ) Recycling, Potable Use ( )Recycling, Other use ( ) Pit Privy ( ) Incineration Toilet ( ) Chemical Toilet
(X) Other- Describe: Hauled to Down Valley Waste for their disposal
14
Final Disposal By:
( ) Absorption trench, Bed or Pit ( ) Underground Dispersal ( ) Above Ground Dispersal ( ) Evapotranspiration ( ) Sand Filter
( ) Wastewater pond (X )Other -Describe Hauled to Down Valley Waste for their disposal
15
Will effluent be discharged into waters of the state? ( )Yes (X )No
16
Percolation Test Result: (to be completed
Minutes per
by Registered Professional Engineer, if the
inch in hole No.1
in hole No.2
made soil absorption test: N/A
Engineer does the Percolation Test)
Minutes per inch in
N/A
hole No.3
No.4
Minutes per inch
Minutes per inch in hole
Name, address & telephone of RPE who
Name, address & telephone of RPE responsible
for design of the system:N/A
17
P--
Applicant acknowldges that the completeness
by the local health department to be made
and the issuance of the permit is subject
information and reports submitted herewith
knowledge and belief and are designed
herin. I further understand that any falsification
said application egal action for erj
of the application is conditional upon such
and furnished by the applicant or by the local
to such terms and conditions as deemed necessary
and required to be submitted by the applicant
to be relied on b -. a department of health
or ,:;.renseotaion may result in the
further mandatiory and additional test and reports as may be required
health department for purposed of the evaluation of the application;
to insure compliance with the rules and regulations made,
are or will be represented to be true and correct to the best of my
in evaluationg the same for purposes of issuing the permit applied for
denial of the application or revocation of any permit granted based upon
/
•d by la .
Owners S' ature. Bryan . Hotard Date
•
.,Permit Fee:
Perk Gee:
Total !fees:
Building Permit #:
Septic P erm #• �f
Issue Date: c?..aqs.--,),0 l
Building',. Planning to 0lb
APPROVA DATE