Fillable (OFFICE USE ONLY) BRAZOS COUNTY ROAD AND BRIDGE (Brazos County, Texas)

Fill Online, Printable, Fillable, Blank (OFFICE USE ONLY) BRAZOS COUNTY ROAD AND BRIDGE (Brazos County, Texas) Form

Use Fill to complete blank online BRAZOS COUNTY, TEXAS (TX) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

(OFFICE USE ONLY) BRAZOS COUNTY ROAD AND BRIDGE (Brazos County, Texas)

On average this form takes 33 minutes to complete

The (OFFICE USE ONLY) BRAZOS COUNTY ROAD AND BRIDGE (Brazos County, Texas) form is 7 pages long and contains:

  • 1 signature
  • 45 check-boxes
  • 105 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Brazos County, Texas

BROWSE BRAZOS COUNTY, TEXAS (TX) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PERMIT#___________________
(OFFICE USE ONLY)
BRAZOS COUNTY
ROAD AND BRIDGE DEPARTMENT
APPLICATION FOR OIL AND GAS PERMIT
The undersigned, as Applicant/Owner of the subject property listed below hereby makes application for an Oil and Gas/Floodplain
Development Permit from Brazos County.
SECTION 1: PROPOSED DEVELOPMENT (To be completed by APPLICANT)
1. APPLICANT INFORMATION
Name:
________________________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________________
City, State, Zip Code:
________________________________________________________________________________________________________
Property Address:__________________________________________________________________________________________
City, State, Zip Code:
________________________________________________________________________________________________________
Legal Description:_________________________________________________________________________________________
Lease Name:______________________________________________________ Well No._______________________________
Telephone (include e-mail if desired):
_____________________________/__________________________________________________________________________
Daytime phone E-mail
Applicant is a: (check applicable status)
Corporation Partnership Individual (s) Other _______________________
SECTION 2: GENERAL PROVISIONS (APPLICANT To read and sign)
1. No work of any kind may start until a permit is issued.
2. The permit may be revoked if any false statements are made herein.
3. If revoked, all work must cease until permit is re-issued.
4. Development shall not begin or occupied until a permit is issued.
5. The permit will expired if no work is commenced within a six month of issuance.
6. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable inspections required
to verify compliance.
SECTION 3: DESCRIPTION OF WORK (Check all applicable boxes :)
A. STRUCTURAL DEVELOPMENT
ACTIVITY
( Check all that apply )
New Structure
Addition
Demolition
Alteration
Relocation
Replacement
B.
OTHER DEVELOPMENT ACTIVITIES
Clea
ring Filling Mining Drilling Grading Excavation
Wate
rcourse Alteration (Including Dredging and Channel Modifications)
Dra
inage Improvements
Oth
er (Please specify)________________________________________________________________
C.
MATERIALS THAT WILL BE BROUGHT IN (If you choose fill in Section B, you must complete).
_____ The
amount of fill taken out
_____ The
amount of fill brought in
_____Tota
l amount of fill for the project
Brief description o
f the project:
Afte
r completing SECTION 1-3, APPLICANT should submit form to the Local Administrator for review.
THE APP
ICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO THIS APPLICATION
ARE TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE. (For Oil and Gas a company representative may
sign.)
_____________
____________________
Property Owners Name (Printed)
_________________________________ _____________________
Property Owners Signature Date
click to sign
signature
click to edit
SECTION 4: FLOODPLAIN DETERMINATION (To be completed by a Floodplain Representative)
The proposed development is located on FIRM Panel No._______________________________,Dated_______________________.
The Proposed Development:
Is NOT
located in a Special Flood Hazard Area.
Is partially located in the SFHA, but building development is
not.
Is located in the Special Flood Hazard Area
FIRM zone designation_______________.
“100-Year” flood elevation at the site is:_________ft.
Is located in the floodway.
SECTION 5: PERMIT DETERMINATION (To be completed by a Floodplain Representative)
I have determined that the proposed activity: Is Approved Permit #________________________________
Is not
SIGNED________________________________________________________DATE____________________________________
The LOCAL FLOODPLAIN REPRESENATIVE will complete Section 6 based upon inspection of the project to ensure
compliance with Brazos County. A copy of all inspections will be given to you at the completion of the project.
SECTION 6: COMPLIANCE ACTION (To be completed by a Floodplain Representative)
The LOCAL FLOODPLAIN REPRESENATIVE will complete this section as applicable based on inspection of the project to
ensure compliance with Brazos County.
INSPECTION #1 DATE:_______________ BY____________________________
DEFICIENCIES: YES NO
INSPECTION #2 DATE:_______________ BY____________________________
DEFICIENCIES: YES NO
INSPECTION #3 DATE:_______________ BY____________________________
DEFICIENCIES: YES NO
BRAZOS COUNTY
ROAD AND BRIDGE DEPARTMENT
INFORMATION & CONTACT SHEET
APPLICATION INFORMATION (Complete as much information as possible)
C
ompany Name: ______________________________________ Contact Person:___________________________________
Address: _____________________________________________ Phone#__________________________________________
City, State, Zip:_______________________________________ Email:___________________________________________
Phone:_______________________________________________
PROPERTY INFORMATION (Office Use)
P
roperty Owner:_______________________________________ Land Area (Acres):_________________________________
Address: _____________________________________________ Property ID#:______________________________________
City, State, Zip:_______________________________________ Legal:____________________________________________
_________________________________________________
DEVELOPMENT INFORMATION
Pipeline
Oil Well Pipeline Above Ground Valves Yes No
A
PI#________________________________________________ Date Submitted:___________________________________
_
RRC Permit#_________________________________________ Date Approved:___________________________________
Well Name:__________________________________________ Completion:______________________________________
(Office Use)
Well#_______________________________________________
Entrance Road Name:__________________________________ Culvert Installed:__________________________________
(Office Use)
Beginning Date of Work:_______________________________ Ending Date of Work:______________________________
New Drill Recompletion Amended Re-Enter Re-Class Field Transfer
FLOODPLAIN INFORMATION (Office use)
Yes No (SFHA) on parcel not drilling pad
A Zone AE Zone
B
ase Flood Elevation:___________ Firm Panel:_____________________________________
RE
GULATORY ANALYST
N
ame [
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:________
____________________________________________________________________________________________
City State Zip
Email:______________________________________________________________________________________________________
RIGHT OF WAY M
ANAGER
N
ame [
PRINT]:_________________________________________________Telephone No.:______________________ Fax:_________________
Address:________
____________________________________________________________________________________________
City State Zip
Email:_____________________________________________________________________________________________________
S
URVEYOR
N
ame [
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:________
____________________________________________________________________________________________
City State Zip
Email:________________________________________________________________________________________________________________________________
ENGINEER
Name [
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:________
____________________________________________________________________________________________
City State Zip
Email:______________________________________________________________________________________________________
FIELD SUPERVISOR
N
ame [
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:________
____________________________________________________________________________________________
City State Zip
Email:________________________________________________________________________________________________________________________________
CO
NSTRUCTION MANAGER
N
ame [
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:________
____________________________________________________________________________________________
City State Zip
Email:________________________________________________________________________________________________________________________________
DRILL
ING COMPANY
Name
[
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:______________
______________________________________________________________________________________
City State Zip
Contact Person:_____________________________________Telephone No.:_____________________________________________
NAMES
OF TWO (2) EMERGENCY REPRESENTATIVES WITH SUPERVISORY AUTHORITY OVER ALL OIL AND
GAS OPERATION SITE ACTIVITIES THAT CAN BE REACHED TWENTY-FOUR (24) HOURS A DAY.
Name
[
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:______________
______________________________________________________________________________________
City State Zip
Name
[
PRINT]:_________________________________________________Telephone No.:_______________________ Fax:_________________
Address:______________
______________________________________________________________________________________
City State Zip
NOTICES
1. A separate application shall be made for each well to be drilled, transferred, re-drilled, reworked, converted or
reactivated.
2. Every application for an oil or gas well permit must be in writing and signed by operator, or some person duly
authorized to sign on his or her behalf, and filed with Brazos County.
3. Must submit a letter on company letterhead stating the amount of permitting fee along with the lease name.
Checks can be made payable to Brazos County. (No fee is required if there is no floodplain present on parcel)
4. Application with required attachments shall be submitted to the: Brazos County Road & Bridge Department
2617 W. Hwy 21 Bryan, TX 77803
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

(OFFICE USE ONLY) BRAZOS COUNTY ROAD AND BRIDGE (Brazos County, Texas)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document