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Application for a Brazos County Road and Bridge Department Oil and Gas Floodplain Development Permit

2. APPLICANT NAME*

3. APPLICANT REPRESENTATIVE*

5. APPLICANT EMAIL CONTACT*

6. APPLICANT IS A:*
   -- Select One --CORPORATIONPARTNERSHIPINDIVIDUALOTHER

8. APPLICANT MAILING ADDRESS*

10. APPLICANT MAILING ADDRESS*

    CITY, STATE, ZIP CODE

12. APPLICANT PHONE CONTACT*

13. DEVELOPMENT DETAILS:*
    -- Select One --OIL WELLPIPELINE LOCATIONVALVE NEW - OR REPAIRBUILDING PAD OR ROAD

    WHAT IS THE PROJECT?

15. ADDITIONAL PROJECT DETAILS:*
    -- Select One --NEW DRILLRECOMPLETIONAMENDEDRE-ENTERRE-CLASSFIELD TRANSFER

17. API NUMBER:

18. RRC PERMIT#

19. ABOVE GROUND PIPELINE VALVES
    -- Select One --YESNO

21. WELL NAME

22. WELL #

23. ENTRANCE ROAD NAME

25. LEASE AND OR WELL NAME

27. POTENTIAL DEVELOPMENT SITE PROPERTY ADDRESS*

    YOU WILL NEED TO PROVIDE PROOF OF CURRENT ADDRESS. CONTACT BRAZOS COUNTY 911 DISTRICT (979) 779-0911TO RECEIVE ADDRESS INFORMATION.

29. POTENTIAL DEVELOPMENT SITE PROPERTY ADDRESS*

    CITY, STATE, ZIP CODE

31. LEGAL DESCRIPTION

33. PROPERTY ACERAGE

34. PROPERTY ID:

36. STRUCTURAL DEVELOPMENT ACTIVITY

    1. NEW STRUCTURE
    2. ALTERATION
    3. ADDITION
    4. RELOCATION
    5. DEMOLITION
    6. REPLACEMENT

37. OTHER DEVELOPMENT ACTIVITIES

    1. CLEARING
    2. FILLING
    3. MINING
    4. DRILLING
    5. GRADING
    6. EXCAVATION
    7. WATERCOURSE ALTERATION
    8. DRAINAGE IMPROVEMENTS
    9. OTHER

38. MATERIAL BROUGHT IN?*

    1. FILL BROUGHT IN
    2. FILL TAKEN OUT
    3. NO CHANGE IN FILL

40. REGULATORY ANALYST

42. NAME

43. PHONE

44. EMAIL

46. RIGHT OF WAY MANAGER

48. NAME

49. PHONE

50. EMAIL

52. SURVEYOR

54. NAME

55. PHONE

56. EMAIL

58. ENGINEER

60. NAME

61. PHONE

62. EMAIL

64. FIELD SUPERVISOR

66. NAME

67. PHONE

68. EMAIL

70. CONSTRUCTION MANAGER

72. NAME

73. PHONE

74. EMAIL

76. DRILLING COMPANY

78. NAME

79. PHONE

80. EMAIL

82. EMERGENCY CONTACTS
    TWO REPRESENTATIVES WITH SUPERVISORY AUTHORITY OVER ALL OIL AND GAS OPERATION SITE ACTIVITIES THAT CAN BE REACHED TWENTY-FOUR (24) HOURS A DAY.

    TWO REPRESENTATIVES WITH SUPERVISORY AUTHORITY OVER ALL OIL AND GAS OPERATION SITE ACTIVITIES THAT CAN BE REACHED TWENTY-FOUR (24) HOURS A DAY.

84. NAME*

85. PHONE*

87. NAME*

88. PHONE*

Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit

* indicates a required field