ATTACHMENT A AREA TO BE COVERED BY DELEGATION AGREEMENT CAMPBELL COUNTY (shaded area) WYOMING NOTE: Small wastewater facilities shall include all of C

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6 ATTACHMENT A AREA TO BE COVERED BY DELEGATION AGREEMENT CAMPBELL COUNTY (shaded area) WYOMING NOTE: Small wastewater facilities shall include all of Campbell County. Publicly owned sewage collection facilities and publicly owned water distribution facilities shall include Campbell County, excluding the area within the current city limits of the City of Gillette.

7 ATTACHMENT B R E S O L U T I O N COUNTY COMMISSIONERS REGULAR MEETING SCHEDULE RESOLUTION No. BE IT RESOLVED by the Board of County Commissioners, Campbell County, Wyoming, that the Campbell County Public Works Executive Director (aka County Engineer), is hereby designated as the Delegated Local Official whom we hereby authorize to enforce and administer the review and permitting delegated in the Delegation Agreement By and Between the Wyoming Department of Environmental Quality and Campbell County, Wyoming dated September, IT IS FURTHER RESOLVED that the Public Works Executive Director may employ the following staff members in the County to assist in the review and permitting duties of this delegated authority: Engineering Services Manager; Construction Project Manager; Staff Engineer; Building Code Official. RESOLVED this day of, 20. BOARD OF COUNTY COMMISSIONERS CAMPBELL COUNTY, WYOMING Attest: (Seal) Micky Shober, Chairman Susan F. Saunders, County Clerk Matt Avery, Member Dan Coolidge, Member Chris Knapp, Member Stephen Hughes, Member

8 ATTACHMENT C QUALIFICATIONS Public Works Executive Director (aka County Engineer) Experience: Seven to eight years experience with progressively responsible management and supervisory duties which demonstrates administrative ability and leadership qualities. Experience should be in the public sector and include management of a similar facility and programs. Education/Training: Equivalent to a Bachelor's or Master's degree in Civil Engineering. Training satisfactory to the Wyoming State Board for Engineers for licensing as a Professional Engineer. Licenses, Certificates, or Registrations: State License as Professional Engineer. Engineering Services Manager Experience: Seven to eight years experience in engineering, surveying and drafting field. Education/Training: Equivalent to a Bachelor's or Master's degree in Civil Engineering. Training satisfactory to the Wyoming State Board for Engineers for licensing as a Professional Engineer. Licenses, Certificates, or Registrations: State License as Professional Engineer. Construction Project Manager Experience: Five to six years in managing building construction projects with increasingly responsible supervisory experience. Education/Training: Equivalent to a Bachelor's or Master's Degree in engineering or a related field. Licenses, Certificates, or Registrations: State License as Professional Engineer preferred.*

9 Staff Engineer Experience: Three to four years experience in engineering, surveying, and drafting field. Education/Training: Equivalent to a Bachelor's or Master's degree in Civil Engineering. Licenses, Certificates, or Registrations: State License as Professional Engineer preferred.* Building Code Official** Experience: Seven to eight years experience in building code enforcement, with progressively responsible management and supervisory duties which demonstrate leadership qualities. Education/Training: Equivalent to an Associate s Degree in Business/Public Administration or related field. Licenses, Certificates, or Registrations: Must be current: International Code Council Certified Building Official (CBO) Valid driver s license Must be current or obtained within a specified time frame as defined upon employment: Residential Building Inspector (B1) Commercial Building Inspector (B2) Building Plans Examiner (B3) Residential Plans Examiner (R3) * If the Construction Manager or Staff Engineer does not hold a current PE license, their permit review will be directed by a P.E. ** The Building Code Official will only participate in the review and permitting of the small wastewater facilities.

10 ATTACHMENT D TABLE OF CONTENTS Regulations for a permit to Construct, Install or Modify Small Wastewater Facilities, Publicly Owned Sewage Collection Facilities, and Publicly Owned Water Distribution Facilities. Section No. Subject: Page No. 1 Authority 1 2 Purpose 1 3 Applicability 1 4 Intent 1 5 Definitions 1 6 Prohibitions 3 7 Permit Required 4 8 Application Requirements 4 9 Application Processing Procedures 5 10 Construction and Operation in Compliance with Issued Permit 5 11 Duration and Termination of Permits; Transfer of Permits 6 12 Renewal of a Permit 7 13 Denial of a Permit 7 14 Modification of a Permit 7 15 Suspension or Revocation of a Permit 8 16 Compliance with State and Local Water Quality Management Plans 9 17 Facilities and Systems not Specifically Covered by These Standards 9 18 Lagoons 9 19 Small Waste Stabilization Ponds 9 20 Validity Clause 9 21 Enforcement 9

11 REGULATIONS FOR A PERMIT TO CONSTRUCT, INSTALL OR MODIFY SMALL WASTEWATER FACILITIES, PUBLICLY OWNED SEWAGE COLLECTION FACILITIES, AND PUBLICLY OWNED WATER DISTRIBUTION FACILITIES. SECTION 1: Authority. This regulation is promulgated pursuant to the Wyoming Environmental Quality Act, W.S through W.S Specifically, W.S stipulates that no person, except when permit authorized, shall: construct, install, modify or operate any small wastewater facilities, publicly owned sewage collection facilities, publicly owned water distribution systems and publicly owned non discharging treatment works. W.S stipulates that to the extent requested, authority to enforce and administer W.S (a) (iii) and (v) shall be delegated to qualifying municipalities, water and sewer districts or Counties. SECTION 2: Purpose. The purpose of these regulations are to prevent, reduce and eliminate pollution and enhance the waters of the State of Wyoming and to protect the health, safety and welfare of the environment and its inhabitants by ensuring that the design and construction of small wastewater facilities, publicly owned sewage collection facilities, and publicly owned water distribution facilities meet the purpose of the Environmental Quality Act. SECTION 3: Applicability. These regulations shall apply to all small wastewater facilities, publicly owned sewage collection facilities, and publicly owned water distribution facilities as defined in Section 5 of these regulations within the boundaries of Campbell County. These regulations supplement and reiterate the DEQ regulations. Specifically, Chapters 3, 11, 12, 23 and 25. SECTION 4: Intent. The design and construction standards included in these regulations are directed toward conventional small wastewater facilities, publicly owned sewage collection facilities, and publicly owned water distribution facilities. These standards impose limiting values of design for which a construction, installation or modification permit application and plans and specifications can be evaluated by the County Engineer or his/her designated staff. The terms shall and must are used when practice is sufficiently standardized to permit specific delineation of requirements or when safeguarding public health or protection of water quality justifies such definite action. Other terms, such as should, recommend, and preferred indicate desirable procedures or methods which allow deviations provided the purpose of these regulations can be accomplished. SECTION 5: Definitions. The following definitions supplement those definitions contained in Section W.S of the Wyoming Environmental Quality Act and the definitions contained in Chapter 3, Section 3 (b) of the Department of Environmental Quality (DEQ) regulations. (a) Absorption system" means a system constructed under the surface of the ground which receives and distributes effluent from a pre treatment device effectively filtering the effluent through soil or media. (b) "Aerobic unit" means a covered, watertight receptacle which receives wastewater. The unit removes settleable solids, floatable material, and a part of soluble organic matter by the use of aerobic biological treatment. (c) "Building drain" means the building drain is that part of the lowest piping of a drainage system which receives the discharge from soil, waste and other drainage pipes inside the walls of the building and conveys it to the building sewer beginning two feet (.6 meters) outside the building wall. 1

12 (d) "Building sewer means the building sewer is that part of the horizontal piping of a drainage system which extends from the end of the building drain and which receives the discharge of the building drain and conveying it to the septic tank or other onsite sewage disposal facility. (e) "Cesspool" means a covered pit into which raw sewage is discharged for final disposal by leaching into the surrounding porous soil. Cesspools are not allowed under these regulations. (f) "Distribution box" means a water tight structure which receives liquid effluent from a septic tank and distributes such effluent in equal portions into two or more pipes leading to the disposal area. (g) "Domestic sewage" means the liquid and water borne wastes derived from the ordinary living processes, free from industrial wastes, and of such character as to permit satisfactory disposal without special treatment. (h) Dosing system means the system of tanks, pumps or syphons, and piping located between the septic tank and soil absorption system which is intended to apply a large quantity of settled wastewater to the absorption system in a short period of time. (i) "Ground water" means subsurface water that fills available openings in rock or soil materials such that they may be considered water saturated under hydrostatic pressure (j) "Hydro geological study" means a study of the occurrence, distribution, quality and movement of the shallow most groundwater of the state and the potential impact of wastewaters on the groundwater. inch. (k) "Impermeable soil" means any soil which has a percolation rate greater than 60 minutes per (l) Maximum daily demand" means the largest daily water use rate which would occur during the calendar year. (m) "Maximum hourly or peak hourly demand" means the largest water use rate which would occur during any one hour during the year. The maximum hourly demand may or may not occur during the maximum daily demand period. (n) "Mobile Home Park" means a parcel or tract of land under the control of a person upon which two (2) or more mobile homes are located on a continual or seasonal non recreational basis regardless of whether a charge is made therefore. (o) "Non discharging treatment works" means any plant or other works used for the purpose of treating, stabilizing or holding wastes without any addition of any pollution or wastes to any waters of the State. (p) "Permit" means written authorization issued by the County Engineer's Office, duly executed, which authorizes the permittee to construct, install, and/or modify the facilities as set forth in these regulations. (q) Privy" means a covered pit into which only urine and fecal material are discharged for final disposal by leaching into the surrounding soil or by hauling to an approved disposal site. Greywater or toilet carriage water may not be discharged into a privy. 2

13 (r) "Public water supply" means any water supply being distributed by twenty or more service connections utilized to furnish water for human consumption either in preparing foods or beverages for inhabitants of residences or business establishments. A public water supply includes the source, treatment system, waste disposal system, distribution system, service connections, finished water storage and pumping stations. (s) Publicly owned or controlled facility" means a system for which a municipality, County, water and sewer district, or improvement district receives a permit to discharge and/or construct, modify, or install any public water supply, sewerage, system, treatment works, disposal system or other facility capable of causing or contributing to pollution. If an entity other than a municipality, county, water and sewer district or improvement district is the applicant or recipient of a permit under Chapter II and III of the Wyoming Water Quality Rules and Regulations, the facility will be deemed to not be publicly owned or controlled: (t) "Pump Tank means a tank in which the dosing pumps or syphons are installed. (u) "Seasonal high groundwater table" is the highest elevation reached by the groundwater during the wet season of the year (usually spring or early summer). (v) Septic tank" means a liquid tight receptacle which receives for storage and digestion, raw sewage from a building sewer, and which has been designed and constructed so as to retain the solids and to allow the liquids to discharge through a secondary system of piping into a disposal area. (w) "Sewage collection system" means a sewerage system, including pipelines, conduits, storm sewers, pumping stations, force mains, and all other construction, devices, appurtenances and facilities used for collection or conducting wastes to an ultimate point for treatment or disposal. (x) "Small wastewater system" means any sewerage system, disposal system or treatment works having simple hydrologic and engineering needs which is intended for wastes originating from a single residential unit serving no more than four families or which distributes 2,000 gallons or less of domestic sewage per day. (y) "Soil" means all unconsolidated material overlaying bedrock. (z) "Water distribution facility means pipelines, conduits, pumping stations, storage facilities and all other constructions, devices, appurtenances and facilities used for collecting or conducting water from the source to an ultimate point for treatment and from the treatment facility to the service connections of a public water supply. SECTION 6. Prohibitions. No person shall, except when authorized by permit issued pursuant to these regulations: (a) Construct, install, or modify any small wastewater facilities, publicly owned sewage collection facilities, publicly owned water distribution facilities, or publicly owned non discharging treatment works. (b) Construct, install, or modify any small wastewater facilities, publicly owned sewage collection facilities, publicly owned water distribution facilities, or publicly owned non discharging treatment works in non compliance with the terms and conditions of an issued permit. 3

14 (c). Construct, install, or modify small wastewater facilities, publicly owned sewage collection facilities, publicly owned water distribution facilities, or publicly owned nondischarging treatment works with a permit that has expired or has been suspended or revoked. (d) Discharge wastes into any small wastewater system which is inconsistent with the type and/or quantity of wastes for which the facility is designed. SECTION 7. Permit Required; Control of Construction, Installation and Modification Permits; Responsibility on Issued Permits; Exemptions. (a) Construction, installation, or modification of small wastewater facilities, publicly owned sewage collection facilities, and publicly owned water distribution facilities shall be allowed only in accordance with the terms and conditions of permits issued pursuant to the provisions of these regulations. (b) No construction, installation or modification of small wastewater facilities, publicly owned sewage collection facilities, and publicly owned water distribution facilities shall be allowed unless a permit to construct, install or modify has been obtained from the County Engineer or the DEQ. (c). The issuance of a permit to construct does not relieve the permittee of its responsibility to properly plan, design, construct, operate and maintain the facility described in the application and permit conditions. SECTION 8. Application Requirements. The following procedures will be followed in applying for a permit: (a) Any person who proposes to construct, install or modify a facility required to be permitted under Section 6 shall submit a written application on forms provided by the County Engineer. (Attachment E). (b) The applications for a permit to construct, install or modify must be accompanied by three hard copies and one digital copy of plans, specifications, design data or other pertinent information covering the project, and any additional information required by the County Engineer. (c) All plans and specifications must conform to common engineering practices and include the following: (i) Plans and specifications for SMALL WASTEWATER FACILITIES shall meet, as a minimum, the requirements set out in current adopted version of the DEPARTMENT OF ENVIRONMENTAL QUALITY Chapter 25; and the requirements on the application for Small Waste Water permit available from the Campbell County Public Works Building Division. Chapter 25 Rules and the Small Waste Water permit are contained in the appendix of this agreement. (ii) Design, plan, and specification requirements for PUBLICLY OWNED WATER DISTRIBUTION FACILITIES shall meet as a minimum the requirements set out in the current adopted version of the DEPARTMENT OF ENVIRONMENTAL QUALITY Chapter 12; and the requirements listed on Attachment E from the Campbell County Department of Public Works. Chapter 12 Rules are set forth in the Appendix of this Agreement. (iii) Design, Plan, and Specification requirements for PUBLICLY OWNED SEWERAGE COLLECTION AND TREATMENT FACILITIES shall meet as a minimum the requirements set out in the current adopted version of the DEPARTMENT OF ENVIRONMENTAL QUALITY Chapter 11; and the requirements listed 4

15 on Attachment E from the Campbell County Department of Public Works. Chapter 11 Rules are set forth in the Appendix of this Agreement. SECTION 9. Application Processing Procedures. All permit applications received will be processed in the following manner: (refer to the appropriate flow chart for the application.) (a) The County Engineer shall review each application and take final action within 30 days from the date the application is received. (b) Incomplete applications will not be processed. The County Engineer shall promptly notify the applicant of the deficiencies in the submitted permit application package. (c) All plans and specifications must meet or exceed minimum design standards and these regulations. (Refer to DEPARTMENT OF ENVIRONMENTAL QUALITY Chapters 3, 10, 11, 12 and 25, as referenced in the Appendix, for additional requirements.) (d) Applications for a modification of an existing permitted facility to increase the capability to treat, hold, or dispose of wastes may be approved requiring only the modification needed to meet the minimum design standards. Facilities not in compliance with these regulations will require additional modifications to other portions of the facility to bring the facility into compliance with these regulations. (e) Each application must be submitted with all supporting data necessary for review. Processing of the application with respect to recommendations or required changes will be done in accordance with the provisions of applicable statutes, rules and regulations. (f). The County Engineer shall promptly notify the applicant of the final action taken on the application. If the conditions of the permit are different from the proposed application submitted by the applicant for review, the notification shall include reasons for the changes made. (g) If, upon review of an application, the County Engineer determines that a permit is not required, the County Engineer shall notify the applicant of this determination. If another Governmental entity has jurisdiction, then the applicant will be notified as to which entity has jurisdiction. Such notification shall constitute final action on the application by the County Engineer. (h) If, upon review of an application, the County Engineer determines that a permit should not be granted, the County Engineer shall notify the applicant of the permit denial and state the reasons for denial. (i) If the applicant is dissatisfied with the permit conditions or denial of any permit issued by the County Engineer, he may request a hearing in accordance with Section 13 (c). SECTION 10. Construction and Operation in Compliance with Issued Permit. The permittee shall: (a) Conduct all construction, installation, or modification of any facility permitted consistent with the terms and conditions of the permit. Unauthorized changes, deviations or modifications will be a violation of the permit. A new application or amended application must be filed with the County Engineer to obtain modification of a permit. No modification shall be implemented until a new or modified permit has been issued or a waiver given pursuant to subsection (b). (b) Requests may be submitted for authorization to utilize materials and/or procedures different 5

16 from those specified in the terms of the issued permit. Such requests shall be directed to the County Engineer. A waiver may be granted if materials and/or procedures specified in the permit cannot be obtained or accomplished, and alternative materials and procedures meet minimum standards. In order to prevent undue delay during construction, the County Engineer may grant a waiver orally, upon oral request, provided that this oral request is followed by a written request within five days. Any changes shall be noted on the permit. (c) Conduct the operation in accordance with statements, representations, and procedures presented in the complete application and supporting documents as accepted and authorized by the County Engineer. (d) Notify the Engineer at least 24 hours prior to backfilling the system. The County Engineer will perform a final inspection of the installation to ensure compliance with these regulations. The compliance section of the permit will then be signed. If the applicant does not notify the County Engineer, the following actions may be taken or required by the County Engineer: (i) Digging up the system to show compliance with these regulations, (ii) Revocation of the permit, (iii) Legal action, or (iv) All of the above. SECTION 11. Duration and Termination of Permits; Transfer of Permits. (a) The duration of construction, installation or modification permits will be variable, but shall not exceed one year from the date of issuance. The expiration date will be recorded on each permit issued. Those permits issued without a specified expiration date will be in force no more than one year from date of issuance. (b) Permits will be issued only to the official applicant of record, who must be the owner of the permitted facility, for only the type of construction of record and shall be automatically terminated: (i) Within 60 days after sale or exchange of the facility unless application for transfer is received pursuant to subsection (a) and (b) of this section. (ii) When construction is completed. Except that conditions included in the permit will remain in effect throughout the life of the facility. (i) (ii) Upon issuance of a new, renewed or modified permit. Upon written request of the permittee. (A) Permits shall be transferred to new owners by the completion and submittal of ownership transfer forms by the new owner to the County Engineer. The new owner shall also submit a written request from the existing owner to transfer ownership. The County Engineer shall act within 30 days after receipt of the request. (B) Any conditions established in a construction, installation or modification permit will be automatically transferred to the new owner whenever a transfer of ownership of the facility is submitted. 6

17 SECTION 12. Renewal of a Permit. A permit may be renewed where construction has not been completed by contacting the County Engineer stating that there will not be any changes in the plans for construction, installation, or modification of a permitted facility no less than 30 days prior to the expiration date of the permit. SECTION 13. Denial of a Permit. (a) The County Engineer may deny a permit for any of the following reasons: (i) The application is incomplete or does not meet applicable minimum design and construction standards as specified in these regulations. (iv) The Project, if constructed, will cause violation of applicable state surface or groundwater standards. (v) The project does not comply with applicable state and local water quality management plans as specified in Section 16 of these regulations. (vi) No new small wastewater system shall be approved for a building to which connection to a sanitary sewer is cost effective, and the connection is allowed by the controlling authority for the sanitary sewer. (vii) Other justifiable reasons. (b) If the County Engineer proposes to deny issuance of a permit, the applicant shall be notified of the intent to deny and the reason for denial. (c) In the case of the denial or conditioning of a permit by the County Engineer, the applicant, if he so desires, may request a hearing before the Campbell County Commissioners. A request for hearing shall be made in writing within 20 days of notification of the denial to the County Engineer's Office and shall state the grounds for the request. Any hearing shall be conducted pursuant to the regulations of Campbell County. The Campbell County Commissioners may not issue a waiver from the design standards to these regulations. SECTION 14. Modification of a Permit. Either before construction is completed, upon permitted small wastewater facilities, publicly owned sewage collection facilities, and publicly owned water distribution facilities, or during the review of a proposed facility application, the County Engineer may, for good cause, modify a construction permit. (a) When reviewing an application or before construction on a facility is completed, the County Engineer may modify a permit due to the following reasons: (i) Existing, unknown or changing site conditions which would prevent construction and resultant operation from complying with these regulations; or (ii) (iii) modification; or (iv) Receipt of additional information; or Incomplete application on review items where the applicant agrees with the Review items not in compliance with minimum standards where the applicant agrees 7

18 with the modification; or regulations. (v) Any other reason necessary to effectuate applicable statutes, standards or (b) The County Engineer shall notify the permittee by registered or certified mail of intent to modify the permit. (c) Such notification shall include the proposed modification and the reasons for modification and time frame to have modifications constructed, installed or operational. Modification requirements shall be implemented before construction, installation, or modification of a facility is completed. (d) The modification shall become final within 20 days from the date of such notice unless within that time the permittee requests a hearing before the Campbell County Commissioners. Such request for hearing shall be made in writing to the County Engineer's Office and shall state the grounds for the request. Any hearing held shall be conducted pursuant to the regulations of Campbell County. (e) A copy of the modified permit shall be forwarded to the permittee as soon as the modification becomes effective. SECTION 15. Suspension or Revocation of a Permit. The County Engineer may suspend or revoke a permit before construction, installation or modification of a facility is completed for the reasons set forth below, in item (b). (a) Before a permit may be suspended or revoked, the permittee shall be given an opportunity to show compliance with all lawful requirements for the retention of the permit. (b) The County Engineer shall notify the permittee of its intent to suspend or revoke the permit in the event that it becomes necessary due to: (i) Non compliance with the terms of the permit; or (ii) Unapproved modifications in design or construction; or (iii) False information submitted in the application; or (iv) Changing site conditions which would result in violations of applicable regulations; (v) Non compliance with any requirements of these regulations; or (vi) Any other reason necessary to effectuate applicable statutes, standards or regulations. (c) The notification shall include the reasons for suspension or revocation. (d) The suspension or revocation shall become final 20 days from the date of such notice unless, within that time, the permittee requests a hearing before the Campbell County Commissioners. Such a request for hearing shall be made in writing to the County Engineer's Office and shall state the grounds for the request. Any hearing held shall be conducted pursuant to the applicable regulations. 8

19 SECTION 16. Compliance with State and Local Water Quality Management Plans. No permit may be issued for any facility which is in conflict with an approved water quality management plan prepared under Sections 303, 208 and/or 201 of the Federal Clean Water Act, as amended. SECTION 17. Facilities and Systems not Specifically Covered by These Standards. This section is provided to encourage new technology and equipment and provide a process for evaluation and permitting of designs which deviate from these regulations. The construction of innovative facilities and processes not in compliance with these regulations will be permitted provided that the facility, when constructed, can operate meeting the purpose of these regulations. (a) Each application for a permit to construct a facility not in compliance with these regulations shall be evaluated jointly by the County Engineer and the Department of Environmental Quality; Water Quality Division on a case by case basis using the best available technology. The following information should be included with the application: (i) Data obtained from a full scale, comparable installation which demonstrates the acceptability of the design and/or, (ii) (iii) (iv) Data obtained from a pilot plant operated under the design condition for a sufficient length of time to demonstrate the acceptability of the design and/or, Data obtained from a theoretical evaluation of the design which demonstrates a reasonable probability of the facility meeting the design objectives; and An evaluation of the flexibility of making corrective changes to the constructed facility in the event it does not function as planned. (b) If an applicant wishes to construct a pilot plant to provide the data necessary to show the design will meet the purpose of the act, a permit to construct must be obtained. SECTION 18 Lagoons will be permitted through DEQ. (Refer to DEQ Chapter 11) 25) SECTION 19 Small Waste Stabilization Ponds will be permitted through DEQ. (Refer to DEQ Chapter SECTION 20. Validity Clause. If any section, subsection, sentence, clause, or phrase of these rules and regulations is, for any reason, held to be unconstitutional or invalid, such decision shall not affect the validity of the remaining portions of these rules and regulations. SECTION 21. Enforcement. Any person, firm or corporation violating the provisions of this regulation shall be subject to a civil penalty of up to $250 per day. Each and every day, or portion thereof, during which any violation of any of the provisions of the regulation is committed, continued or permitted shall be considered a separate offense. Upon a determination of committing of any such violation, such a person will be subject to a fine of up to $250 per day. 9

20 ATTACHMENT E CAMPBELL COUNTY PUBLIC WORKS 500 S. GILLETTE AVENUE SUITE 1400 GILLETTE, WYOMING (307) APPLICATION FOR PERMIT TO CONSTRUCT 1. Name of Project: Permit Number 2. Location of Project: Sec. Township Range or Lot Block Subdivision 3. Type of Facility: Small Wastewater (less than 2000 gal/day) Sewage Collection Water Distribution 4. Brief description of project: 5. Does this project include: a. Public water supply well? Yes No If yes, list State Engineer permit number (s) b. Potable water supply pumping station? Yes No If yes, what is the design flow? GPM c. Potable water storage facility? Yes No If yes, what is the size? gal d. Sanitary sewage pumping station and force main? Yes No If yes, what is the design flow? gal e. Potable water mains? Yes No If yes, what is the additional peak day demand? gal/day Has a nodal analysis been completed for volume and pressure? Yes No f. Sanitary sewage collection lines? Yes No If yes, what is the additional average daily volume of wastes? gal/day g. Storm sewer lines? Yes No If yes, what is the total lineal feet? L.F. h. Public streets? Yes No If yes how many miles of: Arterial Street miles Collector Street miles Local Street miles

21 i. Earthwork Yes No If yes how many: Cubic yards of cut Cubic yards of fill Feet of maximum cut Feet of maximum fill 6. Three sets of design drawings and specifications are attached. I understand that one set will be returned to applicant or applicant s engineering firm with permit to construct. 7. I certify that the above described project has been submitted in accordance with local and state rules and regulations. I have authorized the following engineering and testing firms to act upon my behalf during the design and construction phases of the project. They are authorized upon my behalf to receive and release correspondence regarding this project to the governing body (ies). Name of Owner of the Project: Mailing Address: City, State, Zip: Business Phone Home Phone Signature of Owner Date ENGINEERING FIRM TESTING FIRM* Name: Name: Address: Address: Business Phone Business Phone Name of Professional Engineer Wyo. P.E. Number * If the Engineering firm is responsible for quality control and testing on the project, write SAME in this line.

22 ATTACHMENT F CAMPBELL COUNTY PUBLIC WORKS 500 S. GILLETTE AVENUE SUITE 1400 GILLETTE, WYOMING (307) PERMIT TO CONSTRUCT Construct Modify Permit No. Date Issued Improve Name of Facility: Applicants Name: Mailing Address: City, State, Zip: This permit hereby authorizes to construct, install or modify a according to the procedures and conditions of Application No. The facility is located in This permit shall be effective for a period of one (1) year from the date of issuance of this permit. The issuance of this permit provides that Campbell County has evaluated and determined that the application meets minimum applicable construction and design standards. The compliance with construction standards and the operation and maintenance of the facility to meet the applicant s engineer s design is the responsibility of the applicant, owner or operator. Nothing in this permit constitutes an endorsement of the construction or the design of the facility described herein. This permit indicates only that standards of design and construction required by the Construction Specifications and Design Standards have been met. The County assumes no liability for, and does not, in any way, guarantee the performance of the permittee in the exercise of its activities allowed under this permit. The permittee understands that it is solely responsible to any third parties for any liability arising from construction or operation of the facility described herein.

23 By the issuance of this permit, Campbell County does not, in any way, waive its sovereign immunity. The permittee shall allow the authorized representatives from Campbell County, upon the presentation of credentials and during working hours, to have access to inspect the facilities at the above locations for the purpose of compliance with the provisions of this construction permit. The permittee or his agent shall notify the Campbell County Public Works Office 24 hours prior to any construction and submit a construction schedule and the completion date of the stated project. Nothing in this permit shall be construed to relieve the permittee from any responsibilities, liabilities or penalties established pursuant to any applicable State or County law or regulation. The issuance of this permit does not convey any property rights in either real or personal property, or any exclusive privileges, nor does it authorize any injury to private property or any invasion of personal rights, nor any infringement of Federal, State or Local laws or regulations. Should construction of this facility be pursued prior to approval of plat/s by the Campbell County Board of Commissioners, all risks and associated costs of this decision shall be borne by the applicant. Campbell County reserves the right to require modifications and or changes to these facilities until the Campbell County Board of Commissioners approve plat/s. Authorized by: Kevin C. King, P.E. Delegated Local Official 1. Record drawings to be provided to Campbell County Public Works on Mylar and in electronic DXF format within 50 days of completion of construction. Failure to furnish signed and sealed As Constructed plans with the Engineer of Record signature, along with the Operation & Maintenance Manuals will result in fines in the amount of $ per day. Name of Owner: Mailing Address: City, State, Zip: Business Phone: Signature of Owner Date

24 ATTACHMENT G CAMPBELL COUNTY PUBLIC WORKS 500 S. GILLETTE AVENUE STE 1400 GILLETTE, WYOMING (307) Records and Information Permit No. Name of Facility: Applicants Name: Mailing Address: City, State, Zip: Each permit application shall be assigned a Permit Number as soon as the application is received by the Department of Public Works. At this time, a project file will be started and will be kept on file at the Campbell County Public Works Office, 500 South Gillette Avenue, Suite 1400, Gillette, WY The File shall include: Plans and Specifications Application for Permit to Construct (Attachment E) Campbell County Permit to Construct (Attachment F) WDEQ Permit to Construct (If required) Construction Schedule Inspection and Testing Reports Change Orders Project Correspondence As Constructed Drawings Operation and Maintenance Manual(s) Annual Status Report as required by Delegation Agreement Other Other

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