HomeMy WebLinkAboutMFE_Form_04202021 MONTANA DEPARTMENT OF ENVIRONMENTAL QUALITY
MUNICIPAL FACILITIES EXCLUSION
DE
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Subdivision Name: Annie Subdivision Phase 4 Number of lots/parcels/units: 2013
Geocode: 06-0798-02-4-17-18-0000 (this can be found at http://svc.mt.gov/msI/mtcadastral)
Are main extensions necessary to servethe subdivision?? Yes_No If yes, have plans for the mains been submitted
for review?_YesXNo
How will construction of the facilities be financed? Developer
Owner Information:
Owner(s) Name: Russell Hosner LLC
Print name of owner(s) Signature of all owners of record
Address: 7003 Jackson Creek Rd., Bozeman, Montana, 59715
Street or PO Box, City, State, Zip Code
Email: jon@russellhosner.com; drew@russellhosner.com Phone: 406-223-8302
Consultant Information:
Company and Address: WGM Group - 109 E Main Ste. B, Bozeman, MT 59715
Email: afox(@wgmgroup.com Phone: 406-728-4611
Eligibility Requirements: All of the following criteria must be met:
�✓ The project must be provided with adequate municipal water and sewer, solid waste disposal and the
municipality must review storm water plans.
�✓ All the mains necessary to serve the subdivision must be municipality owned, operated and maintained. Privately
owned mains or lift stations make the project ineligible for this exemption.
The municipality must be a 1 sc or 2"d class municipality as described in MCA 7-4-111 or covered under a growth
policy pursuant to Title 76, chapter 1.
The project must be one of the following (check applicable box):
✓ A new division subject to review under the Montana Subdivision and Platting Act, or
Previously divided parcels recorded with Sanitary Restrictions prior to July 1, 1973 or
Divisions or parcels of land that are exempt from Montana Subdivision and Platting Act review
under 76-3-203 or 76-3-207 (1) (a), (b), (d), (e), or(f)
Form continues on next page -------
Submittal Requirements: All of the following items must be submitted:
❑✓ This form, signed by the property owner, and the municipalities' representative.
❑� Copy of Preliminary Plat, COS, Amended Plat or Unit Declaration. The Plat, COS, Am Plat or Unit
Declaration must contain the exemption 76-4-125 (1)(d)(i), (ii) or(iii). If using item (iii), the Plat, COS, Am Plat
or Unit Declaration must also contain the appropriate Platting Act exemption.
❑✓ Vicinity map showing project location.
❑ Applicable zoning ordinances in effect ❑on file
❑ Copy of growth policy, if applicable ❑on file
❑✓ $120 processing fee
Certification:
hereby certify that I am licensed to practice engineering in the State of Montana, I am employed directly or retained by the
municipality providing service and am authorized to sign on behalf of the municipality. In addition, I hereby certify that:
1. The existing water and wastewater systems are in compliance with the provisions of Title 75, chapters 5 and 6, and
2. The water and wastewater systems have adequate capacity to meet the needs of the project,and
3. The municipality has or will review plans to ensure adequate storm water drainage and adequate solid waste
disposal.
�Y Gary Fox
2021.04.20
21:05:02-06'00'
4-20-21
(Signature of Professional Engineer) (Date Signed)
Montana P.E. Number 48775
PE Stamp
Send to: MTDEQ Subdivisions
PO Box 200901
Helena MT 59620-0901
Submittal Requirements: All of the following items must be submitted:
❑✓ This form, signed by the property owner, and the municipalities' representative.
❑� Copy of Preliminary Plat, COS, Amended Plat or Unit Declaration. The Plat, COS, Am Plat or Unit
Declaration must contain the exemption 76-4-125 (1)(d)(i), (ii) or(iii). If using item (iii), the Plat, COS, Am Plat
or Unit Declaration must also contain the appropriate Platting Act exemption.
❑✓ Vicinity map showing project location.
❑ Applicable zoning ordinances in effect ❑on file
❑ Copy of growth policy, if applicable ❑on file
❑✓ $120 processing fee
Certification:
hereby certify that I am licensed to practice engineering in the State of Montana, I am employed directly or retained by the
municipality providing service and am authorized to sign on behalf of the municipality. In addition, I hereby certify that:
1. The existing water and wastewater systems are in compliance with the provisions of Title 75, chapters 5 and 6, and
2. The water and wastewater systems have adequate capacity to meet the needs of the project,and
3. The municipality has or will review plans to ensure adequate storm water drainage and adequate solid waste
disposal.
(Signature of Professional Engineer) (Date Signed)
Montana P.E. Number
PE Stamp
Send to: MTDEQ Subdivisions
PO Box 200901
Helena MT 59620-0901