Laserfiche WebLink
STATE OF COLOMDO <br /> ovislow o>= ►Xtow.Mirk AND SAFETY RE�' ' <br /> Clepaftwit of Ng"Rewwm <br /> 1313 Sherman St.,Roam 215 <br /> Denver,t alorado aaao3 F i J ?014 rC o r n a A D o <br /> sIVISION oe <br /> Phone:W3>866.3367 ItECLA1NATION <br /> FAx:g03}832.ato6 DIVISION OF RECLAMATION MINING <br /> MINING AND SAFETY SJIF Y <br /> LIMITED IMPACT OPERATION(11om) <br /> RECLAMATION PERMU <br /> APPLICATION FORM <br /> CHECK ONE: New App[ication(Rule 1.4) -U Conversion Application(Rule 1.11) <br /> Permit#M40Jo---o-- (provide for conversions of existing permits) k 101(e f <br /> The application for a Limited Impact Designated Miming Operation Reclamation Permit contains three major parts: (1)the application <br /> form;(2)Exhibits A J,any required sectiams of Exhibit S and Deotechnical Stability Exhibit,as required by the Office,and outlined in <br /> Rulea 6.1,6.2,63,6.4.19 and 6.5,tW(3)the application fee. When you submit your application,be sure to include one(1)kawd and <br /> WMAlmd original and one(1)copy of the application form,two(2)copies of Exhibits AEI,appropriate sections of 6.4.19 Exhibit S and 6.5 <br /> (Geotxbnical Stability Exhibit),as required,and a chock for the application fee described under(4)below E�tbibiffi should Ig be bound <br /> or in a 3-rWg bindw,maps should be folded to 8 1/2"X i 1"or 8 1 t2"X 14"size. To expedite processing,pieaso provide the information <br /> in die format aid order described in this form <br /> GENERAL OPERATION TNFORKATTON <br /> Type or print ele",to the space provided,an iaformtion described betew <br /> 1. Aaolicxntio oerator or cgn=p=(ume to be ash as RA _ 5-ff Kole —ZAc , <br /> 1.1 Typo of organization(corporation,partnership,etc.): <br /> 2. Operation namge[tAit,mi e or Site game): b <br /> to <br /> '. Perr+?tttEd ac aS�!rt"rw or txIatltr¢ N } `�( u c PrS I tYfci�'p g permitted acres <br /> 4. 3; <br /> 4.1 New Application $1,06A application fee <br /> 4.2 Amendment Application(from 1.10(2)) <br /> 4.3 Conversion Fee(froth 110d to 110(2),(Rule 1.11.2(2)) S1725_00 conversion fee <br /> ii <br /> 5. Pd MWN eommodi WS)to be mined: 2 7 r"�� S i I t� .�iC <br /> 6. Name of owner to the awlacx of atfectt;d t n • ree,e,(' �j�1•� ���� <br /> f. Nun of Owner t0•Me subsurface dau of affemd IM-4:1 <br /> mt�,Q oacra,nos; 0 Surface ❑ Underg� ❑ in-situ <br /> office of <br /> Mined land Reclamation Dow& • Grind prttctim • DumW Active andI kucdve Mk W office Of <br />