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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />OL O ILA D <br />Phone: (303) 8663567 <br />DIVISION O0 <br />RECLAMATION <br />FAX: 003) 932.8106 <br />MINING <br />SAFETY <br />CONSTRUCTION MATERIALS <br />SPECIAL (ll l) OPERATION <br />M-2015-022 RECLAMATION PERMIT APPLICATION FORM <br />The application fora Construction Materials Special 111 Operation Reclamation Permit contains four major parts: (1) the application form; <br />(2) Exhibits A -L, Addendum 1, and any sections of Exhibit 6.5 (Geotechnical Stability Exhibit), as required by the Office, and outlined in <br />Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); (3) the application fee; (4) the Performance Warranty and if required a Financial Warranty. When <br />you submit your application, be sure to include one (1) completed, signed and notarized ORIGINAL and one (1) copy of the completed <br />application form, two (2) copies of Exhibits A -L, Addendum 1, appropriate sections of Exhibit 6.5 (Geotechnical Stability Exhibit), as <br />required, a check for the application fee described under (4) below, and the fully executed Performance Warranty and Financial Warranty, if <br />required. Exhibits should NOT be bound or in 3 -ring binders; maps should be folded to 8 2" X 11" or 8 2" X 14" size. To expedite <br />processing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below <br />I. Applicant/operator or company name (name to be used on the permit): <br />Lary H Inc <br />111 <br />Type of organization (corporation, partnership, etc.): Corporation <br />2. Operation name (pit, mine or site name): Bootleg Quarry <br />3. Permitted acreage: 13.5 Permitted Acres <br />4. New Application: <br />5. Primary commoditle(s) to be mined: Sand, overburden <br />6. Name of owner to the surface of affected land: <br />Henrylyn Irrigation District <br />$898.00 Application Fee <br />7. Name of owner to the subsurface rights of affected land: -Hen ryym Irrigation District _ <br />8. Type of mining operation: II Surface a Underground 1= In-situ <br />9. Location information: The center of the area where the majority of mining will occur: <br />CO Adams _ <br />PRINCIPAL MERIDIAN (check one): ILF6th (Colorado) l Oth (New Mexico) II Ute <br />SECTION (write number): <br />S 1 <br />TOWNSHIP (write number and check direction): T 1 <br />RANGE (write number and check direction): R 65 <br />QUARTER SECTION (check one): M <br />QUARTER/QUARTER SECTION (check one): M <br />GENERAL DESCRIPTION: (the number of miles an rrection <br />North South <br />East ✓ West <br />NW SERV( <br />SW <br />NW SE SW <br />from the nearest town and the approximate elevation): <br />Fmm I nrhhtiit?, CO travel 5 milPg Past nn act 168th Avenue anti 1 mile cn nth nn Httdcnn <br />Road. Entrance will be on the east side of Hudson Road at approximately 5,110 feet in <br />elevation. <br />Office of Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and inactive Mines <br />