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COLORADO <br />Division of Reclamation, <br />Mining and Safety <br />perartment of Na•ura Rvs. ,'Ces <br />1313 Sherman Street, Room 215 <br />Denver, CO 80203 <br />286455 12/13/2017 02;57 PM B: 943 P: 292 LOC CT <br />Page 2 of 25 R $133.25 D $0.00 T $13;25 Clear Creek <br />1111 N1 PFARFAIX VWN 11111 <br />LIMITED IMPACT OPERATION (110(1)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />CHECK ONE _a New Application n Conversion Application (Rule I.I 1) <br />Permit # M- - (provide for conversions of existing permits) <br />The application for a Limited Impact 114(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 b) the Oifiec, and outlined in Rules <br />6.1, 6.2, 6.3, and 6.5, Ud (3) the application fee. When you submit your application, be sure to include one (i) signed and-notarizeA <br />onginal 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 tec described under (4) below. Exhibits should nt be bound or in a 3 -ring binder; maps should be folded to 8 <br />I '2" X I l" or 8 l `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. _Aaplie nt/onerat r or company name (name to be used on the permit,Z SS( --t <br />1.1 Type of organization (corporation, partnership, etc,): _ ` tin S!E <br />2. Operation itmine or site name : _ LC,v, a�-c� # y / s <br />3. Permilted a t be 5 acres or les : q' O . - 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 t 10(2)to i 10(1). (Rule 1.11.2(2)) conversion fee <br />5. Primiia commoditie(s) to be _{� s1lVee` <br />6. Name of o%ner to the surface of affIcted land: <br />7. Name of ow ner to the subsurface rights of affected land: s5 C <br />8. Te of mining o eration: F] Surface a Underground nPlacer <br />r� <br />1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us I •'' i %* t' <br />John W. Hickenlooper, Governor I Mike King, Executive Director I Virginia Brannon, Director 1- <br />