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For County Use Only Planning Department Confirmation of Current Zone District: Print Full Name PARK COUNTY APPLICATION FOR SPECIAL USE PERMIT FOR OIL AND GAS OPERATION NON-REFUNDABLE APPLICATION FEE: $2000 All applicants must submit one complete application and attend a pre-application conference with the Park County Planning Department Staff seven to ten (10) working days prior to the application submittal deadline. Following the acceptance of the complete application the applicant must submit twenty-five (25) collated paper copies or electronic media as requested to the Park County Planning Department on or before the application submittal date. If you have questions regarding this form please contact the Planning Department by phone at (719) 836-4292, e-mail [EMAIL REDACTED], fax (719) 836- 4351, or write to us at P.O. Box 1598 Fairplay, CO 80440. A. APPLICANT AND OWNERSHIP INFORMATION Applicant’s Name: Mailing Address: City: Telephone Email address: Surface estate Owner’s Mailing Telephone Email address: Mineral estate Owner’s Mailing Telephone Email address: B. PROPERTY INFORMATION Complete Legal Description of Property Proposed for the Special Use Permit for Oil and Gas Operation (attach additional page, if necessary): Street Address of Property: Property’s Total Acreage: Current Zone District of Property: ---PAGE BREAK--- Page 2 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 Requirements for a Special Use Permit Article V, Division 10, Section 5-1004 C. APPLICATION REQUIREMENTS 1. Application Fee. An application fee in the amount of $1120 must be paid at the time of submission of the application. Make the check or money order payable to: Park County Planning Department. The fee pays for the typical cost to the County to process the application including the cost of publication of the necessary public notices. Any additional costs that may occur are the applicant’s responsibility. 2. A properly executed Agreement for Payment of Development Review Expenses in the attached form with a $10,000 review expense deposit. 3. Tax receipt-showing payment of current taxes. This can be obtained at the Park County Treasurer’s office. 4. Documentation of surface ownership, evidence of surface owner notification, and copies of any surface ownership agreements and leases affecting the area where the Oil and Gas Operation will be conducted. Name, address, telephone and fax numbers and e-mail address of the owner of the property. 5. Documentation of mineral ownership, including name, address, telephone and fax numbers and e-mail address of the owner of the mineral rights. 6. The legal description (referencing lot and block or tract numbers, homesteads, or metes and bounds), property address and common description of the Parcel on which the Operation is proposed to be located. A copy of the recorded deed or lease to the Parcel should be included. 7. A list of names and mailing addresses of all owners of adjacent property to the property subject to the proposed Special Use Permit. This information is at the Park County Assessor’s Office. 8. Identification of previously approved uses. List any permits, which have been previously approved for the Parcel on which the Oil and Gas Operation is proposed. 9. Characteristics and current condition of the Operation location. Identification of physical characteristics and current conditions of the site where the Operation is proposed to occur, including streams, irrigation ditches, ponds, soils, roads, vegetation, geologic hazards, and any other characteristics requested by the Planning Department to determine potential impacts. Indications if trees or other vegetation have been removed and changes caused either by weather-related or human activity within the past five years. For County Use Only: Initial Receipt of the Required Information ---PAGE BREAK--- Page 3 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 10. A vicinity map; which shall at a minimum include the following: a. The location of the operation on a United States Geological Survey quadrangle map or on a recorded plat if the proposed Oil and Gas Operation is within an approved subdivision, with the location highlighted; b. Topographic features of streams, lakes, ponds, wetlands, contour lines and elevations, within one mile of the proposed well pad; c. All public and private roads that traverse and/or provide access to the proposed Oil and Gas Operation, and identification of the public or private entity have jurisdiction over each road(s); d. Easements recorded or historically used that provide access to or across, or other use of, the Parcel; e. Boundaries of districts, municipalities, subdivisions and special districts within one mile of the site; f. Location of other wells and other Oil and Gas Operations within one mile of the site; g. Location of all Groundwater wells within one mile of the site. 11. A site plan map with north arrow and appropriate scale for the Parcel where the Oil and Gas Operation will occur, indicating the following: a. Utility easements and rights-of-way; b. Existing improvements; c. Proposed facilities such as structures, pipelines, tanks, wells, pits, Flow Lines, impoundment facilities, staging and storage areas and equipment; d. Site features such as Special Flood Hazard Areas, water bodies, drainage patterns, aquatic habitat, vegetative cover, wildlife migration routes and Significant wildlife habitat; e. Existing and proposed topography at five-foot (5ft) intervals or some other interval established by the Planning Department as necessary to portray the direction and slope of the area affected by the Oil and Gas Operation; f. All boundaries of the lease(s) upon which the Operation will take place. 12. Copies of all local, state and federal applications authorizing or required for the Oil and Gas Operation, and permits, when issued. 13. An Oil and Gas operation plan including the method and schedule for drilling, completion, transporting, production, and post-operation. 14. A plan for the management and prevention for noxious weeds on the site. 15. A map that identifies the access route to, and within the Parcel, and a narrative estimating the number and types of vehicles anticipated per day, including weights, which will travel over the route(s). For County Use Only: Initial Receipt of the Required Information ---PAGE BREAK--- Page 4 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 16. Identification of irrigation ditches and other water structures, ownership of water rights appurtenant thereto, and evaluation of any impacts to the structures, water rights or water quality. 17. A written analysis of the impacts of the Oil and Gas Operation to the roadway system within the County. 18. After consultation with the Colorado Division of Wildlife and the U.S. Fish and Wildlife Service, a written analysis of existing wildlife and Sensitive Wildlife Habitat, and the impacts on such with a proposed mitigation plan. 19. A written description of the type, character and density of existing and proposed vegetation within the Parcel and a summary of the impacts of the Oil and Gas Operation of such vegetation with a proposed mitigation plan. 20. An emergency response plan addressing fire protection and hazardous spills, including the name and contact information for the Applicant’s incident responder and a list of proposed signage, access/evacuation routes, and the health care facility(s) anticipated to be used. The emergency response plan shall include a provision for the Oil and Gas Operator to reimburse the appropriate emergency response service providers for cost incurred in connection with the emergency. 21. Water quality non-point source impacts report shall contain: a. An inventory and location of all water bodies within one mile of the proposed Oil and Gas Operation; b. A description of existing water quality of all water bodies within one mile of the Parcel, based upon a current baseline water quality analysis; c. A description of potential Non-Point Source Pollution associated with the proposed Oil and Gas Operation and a proposed mitigation plan. d. Proposed avoidance and mitigation measures to minimize the water quality impacts associated with the Oil and Gas Operation. A proposed mitigation may include an erosion control plan required under Section 5-1004. 22. A cultural, historical, and archeological survey of the Parcel prepared by a qualified professional. 23. A plan that identifies existing and proposed drainage patterns and the methods for controlling erosion during construction and operation phases of the Oil and Gas Operation. 24. A written assessment of wildfire hazards within one mile of the site, and a plan for mitigating wildlife hazards. For County Use Only: Initial Receipt of the Required Information ---PAGE BREAK--- Page 5 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 25. A written assessment of geologic hazards within one mile of the site, and a plan for mitigating geologic hazards. 26. A written summary of the existing uses of the Parcel and the proposed future land uses of the Parcel after completion of the Oil and Gas Operation. 27. Documentation of the basis for any technical infeasibility waiver from the Oil and Gas Operation standards that the Applicant may request pursuant to Section 5- 1007P. 28. The property must be clearly identified with the address and posted according to the Park County address requirements (attached). Note: Refer to Park County Land Use Regulations Article V, for requirements of Major Oil and Gas Operation Permit Review. For County Use Only: Initial Receipt of the Required Information ---PAGE BREAK--- Page 6 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 D. APPLICANT AND LANDOWNER SIGNATURES: The undersigned applicant and landowner hereby verify and affirm that the information contained in this application is complete and accurate. The undersigned applicant and landowner understands and acknowledges that the submission of inaccurate and incorrect information may result in the denial or rejection of the application and/or result in the invalidation of any approvals issued by Park County, Colorado. Applicant: Signed: Print name: If company, state Title/Position: E. VERIFICATION OF DATE OF DELIVERY OF APPLICATION This application was submitted to the Park County Planning Department on the following date and time: Month Day Year Payment of the Applicant Fee was made by: Personal Check Amount $ Cash Amount $ Amount $ APPLICANT MUST ATTEND THE HEARING. IF A REPRESENTATIVE ATTENDS THE HEARING ON BEHALF OF THE APPLICANT, A NOTARIZED LETTER OF CONSENT MUST ACCOMPANY THE APPLICATION. ALL PLANNING COMMISSION HEARINGS WILL BE SCHEDULED FOR THE SECOND WEDNESDAY OF EVERY MONTH. IF A QUORUM IS NOT AVAILABLE, THE HEARING WILL BE SCHEDULED THE NEXT AVAILABLE DATE. PARK COUNTY PLANNING AND ZONING DEPARTMENT AGREEMENT FOR PAYMENT OF DEVELOPMENT REVIEW EXPENSE DEPOSIT For County Use Only: Verification of Date of Delivery and County Receipt of Application Print ---PAGE BREAK--- Page 7 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 APPENDIX C AFFIDAVIT OF UNDERSTANDING I, the undersigned applicant, hereby acknowledge and agree to the following terms and conditions related to the submission of my application to the Park County Development Services Department. 1. ACKNOWLEDGMENT OF APPENDIX C REQUIREMENTS: I understand that, pursuant to Appendix C – Development Review Fees of the Park County Land Use Regulations, all application fees are non-refundable once an application has been received by the County, regardless of its status or outcome. 2. RESPONSIBILITY FOR COMPLETENESS: I acknowledge that it is solely my responsibility to ensure that all required materials, forms, maps, and supporting documentation are submitted in full compliance with the applicable Land Use Regulations and departmental procedures. 3. INCOMPLETE, WITHDRAWN, OR DENIED APPLICATIONS: I understand that any application that is incomplete, withdrawn, or denied—whether administratively or by action of the Board of County Commissioners—shall not be eligible for reimbursement, credit, or transfer of any portion of the fee paid. Any subsequent or corrected submittal shall constitute a new application and require payment of the applicable fee as set forth in Appendix C. 4. CERTIFICATION: I affirm that I have read and fully understand this affidavit and the non- refundable nature of the application fee as described in Appendix C. I further acknowledge that this affidavit shall be retained as part of the official record of my application. Applicant Name: Mailing Address: Project Name / Type: Signature of Applicant Print Name STATE OF ) ss. COUNTY OF Acknowledged before me this day of 20__, Notary Public Witness my hand and official seal. My Commission Expires: ---PAGE BREAK--- Page 8 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 “POSTED” ADDRESS REQUIREMENTS Park County Land Use Regulation Section 7-1207 Address Number Signage Park County requires properties undergoing development to have a permanent address posted. This address post is permanent and is not just for the inspector but is for the use of the Fire Department, Sheriff and Emergency Services. The street address numbers need to be posted on the property prior to the preliminary inspection of the driveway. Numbers shall be attached to a 4” X 4” treated wood or redwood post. The post shall be placed at the driveway no further than 5 feet from the property line. Note: The post must not be placed in the county road right-of-way. The top of the post shall be installed, in a permanent fashion, a minimum of 48 inches above the ground. If the ground is frozen, place the post in a 5 gallon bucket filled with sand or rock until the post can be permanently installed into the ground. The sign specifications are shown with the below two examples. * Note: Contact your local Fire Protection District for signage information Type of Sign specifications for numbers is attached. 1 2 3 4 *Numbers attached to both sides of post 1 2 3 4 ---PAGE BREAK--- Page 9 of 9 Special Use Permit Oil and Gas Operations – Revised October 2025 SIGN SPECIFICATIONS Standard Size - 6” x 18” Standard Color – Green Background with White Reflective Numbers