2016-01-29_PERMIT FILE - M2016002 (2)

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COLORADO , Division of Reclamation, Mining and Safety Dersartmert of Natt".d Rcsourzos 1313 Sherman Street, Room 215 Denver, CO 80203 LIMITED IMPACT OPERATION (110(1)) RECLAMATION PERMIT APPLICATION FORM RECEIVED V JAN 29 2016 ONION OF RECLAMATION MINISNID CHECK ONE: 1 r 1 New Application ❑ Conversion Application (Rule 1.11) Permit # M-2016-002 _ (provide for conversions of existing permits) The application for a Limited Impact 110(1) Mining Operation Reclamation Permit contains three major pans: (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 ad 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 1. Applicant/operator or company name (name to be used on the Hermit): Donald J. Self 2. 3. 4. 1.1 Type of organization (corporation, partnership, etc.): Operation name (nit mine or site name): Double Eagle Permitted acreage (must be 5 acres or less): 3 permitted acres ISS 4.1 New Application 5288.00 application fee 42 Amendment Application 5661.00 amendment fee 4.3 Conversion Fee (from 110(2)to 110(1), (Rule 1.11.2(2)) 5288._ conversion fee s. primary commoditie(s) to be mined: Feldspar and Quartz 6. Name of owner to the surface of affected land:, Donald J. Self 7. Name of owner to the subsurface rights of affected nand; Donald J. Self 8. Type of mining operation: Surface El Underground 0Placer 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://minin8.state.co.us John W. Hickenlooper, Govemor 1 Mike King, Executive Director 1 Virginia Brannon, Director oc rot, • 11176.