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V ! COLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural Resourres <br /> 1313 Sherman Street,Room 215 <br /> Denver,Colorado 80203 <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''/2"X 11"or 8 Ys"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 co an name name to be used on the permit): <br /> t Ks-(rs c ie <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) ! Permitted Acres <br /> 4. Fees: <br /> 4.1 New Application , /y $400.00 Application Fee <br /> 5. Primary commoditie(s)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: <br /> 8. Location information: The center of the area where the majority of mining will occur: <br /> COUNTY: LAI Arv'. P�S <br /> PRINCIPAL MERIDIAN(check one): 6th(Colorado) II loth(New Mexico) n Ute <br /> SECTION(write number): S 3 <br /> TOWNSI-EP(write number and check direction): T 3 3 North South <br /> RANGE(write number and check direction): R 65 East West <br /> QUARTER SECTION(check one): =NE NW SE �_SW <br /> QUARTER/QUARTER SECTION(check one): Q NE NW F1 SE �_SW <br /> 1313 Sherman Street, Room 215,Denver,Co 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br />