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- <br /> KINDS ORGAN <br /> INC. <br /> ENCROACHMENT APPLICATION <br /> Applicant information <br /> Applicant Name/Company Contact Name Title <br /> Weld County Public Works Jay McDonald Director of Public Works <br /> Address City State Zip Code <br /> 1111 H. Street PO Box 758 Greeley CO 80632-0758 <br /> Telephone Number Fax Number Cellular Number E-mail Address <br /> 970-304-6496 970-304-6596 jmcdonald@co.weld.co.us <br /> Applicanrs Representative(contractor/consultant)Name Contact Name Title <br /> NA <br /> Address City State Zip code <br /> Telephone Number Fax Number Cellular Number E-mail Address <br /> Landowner Name(if not applicant) Landowner consent to works obtained? <br /> John Peters ®Yes 0 No <br /> The Applicant hereby applies for permission to construct facilities or equipment under,over,near or crossing the pipeline or within the limits of the pipeline <br /> I right-of-way under the jurisdiction of Kinder Morgan and in accordance with applicable government regulations The proposed encroachment is as follows: <br /> Installation Details <br /> 0 Permanent Installation <br /> ©Temporary Date from: 6///i6 Date to: 11/36. Q Gravel Parking❑Pavement Q es 0 highway <br /> ay No limits?If no,list axel load. <br /> Underground Services If steel,will cathodic protection be applied? <br /> ❑Steel pipe/conduit 0 Plastic pipe/conduit ❑Concrete ❑ Power 0 Other 0 Yes 0 No <br /> Diameter: Diameter: Yards: Voltage: <br /> Overhead Services 0 Power 0 Communications If power,please state voltage <br /> Descnption of Encroachment and the construction procedures to be followed(attach extra pages as required to give full description) <br /> See attached Haul Road design plan and profile. <br /> Tentative construction date(u loo r'> <br /> 06/01/16 <br /> Location of Encroachment(e.g.city,county,state road/street or legal description of property) <br /> SW corner of Section 26, Township 12 North, Range 63 West of the 6th P.M. in Weld County, Colorado. <br /> Coordinates: GPS(Nad 83) <br /> Please attach any maps,plans,profiles.KMZ files,etc. Lat(y). Long(x): <br /> Application Drawing(s)No.(or sketch)Peters 313 Pit Haul Road Design <br /> This form constitutes an APPLICATION ONLY.The encroachment applied for shall not commence until approved by Kinder Morgan. The facilities or <br /> equipment must be constructed in accordance with the guidelines provided by Kinder Morgan. <br /> me c4,--? d � <br /> Name of a M/ <br /> licant or applicant's representative(PRINT) Date(MDOVYY) Si u pplicant pplicanrs representative <br /> KM use only <br /> Reviewed by I Date Received(MM1ODIYY) Date Approved(Mwoonr) <br /> Pipeline/lateral name(e.g.610) KM/Mile Post# Encroachment Number Date ConstrJcted(MulooIYY) <br />