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A17cO LO R RECEDED <br /> Division of F M=2018-0291 LU1a <br /> Mining and N�� <br /> Department of N JLE/m a c 1313 Sherman Stn DIVISION OF RECLAMATION <br /> Denver,Colorado 80203 MINING AND SAFETY <br /> CONSTRUCTION MATERIALS <br /> SPECIAL OPERATION 111(1)(b) <br /> RECLAMATION PERMIT APPLICATION FORM <br /> The application for a Construction Materials Special I I I Operation Reclamation Permit contains four major parts: (1) the <br /> application form;(2)Exhibits A-L,Addendum 1,and any sections of Exhibit 6.5(Geotechnical Stability Exhibit),as required <br /> by the Office,and outlined in Rules 6.1,6.2,6.3,6.5,and 1.6.2(1)(b); (3)the application fee; (4)the Performance Warranty <br /> and Financial Warranty. <br /> When you submit your application,be sure to include one completed,signed and notarized ORIGINAL and one copy of the <br /> completed application form, two copies of Exhibits A-L, Addendum 1, appropriate sections of Exhibit 6.5 (Geotechnical <br /> Stability Exhibit), as required, a check for the $400.00 application fee, and the fully executed Performance Warranty and <br /> Financial Warranty. Exhibits should NOT be bound or in 3-ring binders;maps should be folded to 8''/z" X I I"or 8 %z"X 14" <br /> 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 com an name name to be used on the permit): <br /> 1.1 Type of organization(corporation,partnership,etc.): <br /> 2. Operation name(pit,mine or site name): <br /> 3. Permitted acreage: (must be 30 acres or less) 1 Permitted Acres <br /> 4. Fees: <br /> 4.1 New Application $400.00 Application Fee <br /> 5. Primary commodities)to be mined: •' <br /> 6. Name of owner to the surface of affected land: ^ <br /> 7. Name of owner to the subsurface rights of affected land: M6l h <br /> 8. Location information: The center of the area where the majority of mining will occur: <br /> COUNTY: LAs Atv f—A S <br /> PRINCIPAL MERIDIAN(check one): El 6th(Colorado) n I0th(New Mexico) II Ute <br /> SECTION(write number): S 31 <br /> TOWNSHIP(write number and check direction): T 3 33 North F-1_ South <br /> RANGE(write number and check direction): R G5 East West <br /> QUARTER SECTION(check one): _ 71 NE _F7-1 NW SE SW <br /> QUARTER/QUARTER SECTION(check one): E-1 NE El NW E-1 SE HSW <br /> 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http:!/mining.state.co.us I �e <br /> •1876• <br />