2016-02-18_PERMIT FILE - M2016002 (3)

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AVCOLORADO Division of Reclamation, Mining and Safety RECEIVED Department of Natural Resources e 1313 Sherman Street, Room 215 FEB 18 2016 Denver, CO 80203 DIVISION OF RECLAMATION MINING AND SAFETY LIMITED IMPACT OPERATION(110(1)) RECLAMATION PERMIT APPLICATION FORM C 6,0,rf-D 'Jox"/'5) CHECK ONE: F-4 New Application 1-1 Conversion Application(Rule 1.11) Permit#M- - (provide for conversions of existing permits) The application for a Limited Impact 110(1) Mining Operation Reclamation Permit contains three major parts: (1)the application form; (2) Exhibits A-J, any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in Rules 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 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 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 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. GENERAL OPERATION INFORMATION Type or print clearly,in the space provided,all information described below I. Applicant/operator or company name(name to be used on the permit): Donald J. Self 1.1 Type of organization(corporation,partnership,etc.): 2. Operation name(pit,mine or site name): Double Eagle 3. Permitted acreage(must be 5 acres or less): 3 permitted acres 4. Fees: 4.1 New Application $288.00 application fee 4.2 Amendment Application 66$ 1.00 amendment fee 4.3 Conversion Fee(from 110(2)to 110(1),(Rule 1.11.2(2)) $288.00 conversion fee 5. Primary commodities)to be mined: Feldspar and Quartz 6. Name of owner to the surface of affected land: Federal Government 7. Name of owner to the subsurface rights of affected land: Donald J. Self 8. Type of mining operation: ✓V Surface 1-1 Underground OPlacer 16 GO{� F� 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us +' John W. Hickentooper, Governor I Mike King, Executive Director I Virginia Brannon, Director l x .