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u <br /> DNR COLORADO <br /> CO ` Division of Reclamation, RECEIVED <br /> Mining and Safety <br /> Department of N3:ural P.esource> SEP 15 2017 <br /> 1313 Sherman Street, Room 215 <br /> Denver, CO 80203 DMSION OF RECLAMATION <br /> MINING AND SAFETY <br /> LIMITED IMPACT OPERATION(110(1)) <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE: Fl I New Application fl Conversion Application(Rule 1.11) <br /> Permit#M-a4- 0(o 7 (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): 6-4 g)/ p< Po LL A Ci <br /> 1.1 Type of organization(corporation,partnership,etc.): LAID ) V/.1D1,LA 1- <br /> 2. Operation name(pit, mine or site name): - <br /> 3. Permitted acreage(must be 5 acres or less): f 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: 4/?4 ZO/t//TGr <br /> ���,,;� ."� <br /> 6. Name of owner to the surface of affected land: �� �n <br /> .� �,�, _._� <br /> 7. Name of owner to the subsurface rights of affected land: ; ; :, • . ' • <br /> 8. Type of mining operation: Surface Underground Placer <br /> OF'Cp/ko <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. Hickentooper, Governor I Mike King, Executive Director I Virginia Brannon, Director <br />