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RECEIVED <br />DNR <br />I)ivOionOofRRecAlaDmaO n,Co % JAN 2 9 2016 <br />Mining and Safety <br />Dooartreent of Natural Rcsourc DIVISION OF RECLAIAATION <br />1313 Sherman Street, Room 215 <br />NININGAIDSY <br />Denver,CO 80203 <br />LIMITED IMPACT OPERATION(110(1)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />CHECK ONE: New Application El Conversion Application(Rule 1.11) <br />Permit# M-2016'002 _ (provide for conversions of existing permits) <br />The application for a Limited Impact 110(1) Mining Operation Reclamation Permit contains three major parts: (1)the application form; <br />2)Exhibits A-J, any required sections of Exhibit S and Geotechnical Stability Exhibit,as required by the Office,and outlined in Rules <br />6.1, 6.2, 6.3, and 6.5;and(3)the application fee. When you submit your application,be sure to include one(1)signed and notarized <br />original and one(1)copy of the application form,two(2)copies of Exhibits A-J,and 6.5(Geotechnical Stability Exhibit),as required,and <br />a check for the application fee described under(4)below.Exhibits should not be bound or in a 3-ring binder;maps should be folded to 8 <br />1/2"X 11"or 8 1/2"X 14"size. To expedite 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 />1. Applicant/operator or company name(name to be used on the permit): Donald J. Self <br />1.1 Type of organization(corporation,partnership,etc.): <br />2. Operation name(pit,mine or site name): Double Eagle <br />3. Permitted acreage(must be 5 acres or less): 3 <br />permitted acres <br />4. Fees: <br />4.1 New Application 288.00 application fee <br />4.2 Amendment Application 661.00 amendment fee <br />4.3 Conversion Fee(from 110(2)to 110(1),(Rule 1.11.2(2)) 288.00 conversion fee <br />5. Primary commoditie(s)to be mined: Feldspar and Quartz <br />6. Name of owner to the surface of affected land: Donald J. Self <br />7. Name of owner to the subsurface rights of affected land: Donald J. Self <br />8. Type of mining operation: 112 Surface El Underground DPlacer <br />1313 Sherman Street, Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br />John W.Hickenlooper,Governor I Mike King,Executive Director I Virginia Brannon,Director isle