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�t <br />• <br />u <br />LIMITED IMPACT OPERATION (110) <br />APPLICATION FORM <br />This form contains two major parts: (1) General Operation Information and (2) Exhibits <br />A -G. When you submit your application, be sure to include'tie'."Vs 'd� copfes of the <br />General Operation Information, two copies of Exhibits A -G, and a eck for the <br />application flee described under (4) below. To expedite processing, please provide the <br />information in the format and order described in this form.- 0 <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />1. Applicant /Operator Name: Jeanette Yaklich& Edward M. Yaklich <br />2. Operation Name (Pit, mine or site name): shangri La Pit <br />3. Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* 9.9 permitted acres. <br />($10 x (affected acres) + $25.00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. $125.00 application fee. <br />5. Substance(s) to be mined (e.g., gold /silver /gravel): gravel <br />6. <br />7. <br />8. <br />9. <br />Owners(s) of Substance to be Mined <br />(check applicable box(s)): <br />Owner(s) of Record of Affected Land <br />(check applicable box(s)): <br />Type of Mining Operation <br />(check applicable box(s)): <br />® Private ❑ State Cl Federal ❑ Indian <br />Private ❑ State ❑ Federal ❑ Indian <br />® Surface ❑ Underground ❑ In -situ <br />Location Information. The center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: Custer <br />PRIiICIPLE MERIDIAN check one : ® 6th (Colorado) ❑ 10th (New Mexico)❑ Ute <br />TOWNSHIP (write number and check direction): T 22 ❑ North ® South <br />RANGE (write number and check direction): R 72 ❑ East ® West <br />SECTION (write number): S 30 <br />QUARTER SECTION (check one): ❑-ITF- ® NW ❑ SE ❑ SW <br />QUARTER /QUARTER SECTION (check one): ❑ NE ❑ NW ❑ SE ® SW <br />GENERAL DESCRIPTION: <br />(miles and direction 2-y' miles southwest of Westcliffe, CO. <br />from nearest town and <br />approximate elevation) Elevation 7800' <br />* If the operator is a unit of State or county government, an application fee is not <br />required. A fraction of an acre must be counted as one acre for fee calculation. <br />