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COLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural Resources <br /> 1313 Sherman Street,Room 215 <br /> Denver,Colorado 80203 <br /> CONSTRUCTION MATERIALS <br /> SPECIAL OPERATION I11(1)(b) <br /> RECLAMATION PERMIT APPLICATION FORM <br /> The application for a Construction Materials Special 11 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%"X I I"or 8%"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 /> I. 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(aft,mine or site name): <br /> 3. Permitted acreage:(must be 30 acres or less) Permitted Acres <br /> 4. Fees: <br /> 4.1 New Application q $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: <br /> 8. Location information: The center of the area where the majority of mining will occur: <br /> COUNTY: Lis A v(—Pi S <br /> PRINCIPAL MERIDIAN(check one): al 6th(Colorado) n 1 Oth(New Mexico) n Ute <br /> SECTION(write number): S -3 i <br /> TOWNSHIP(write number and check direction): T 3 3 North South <br /> RANGE(write number and check direction): R (o 5- East West <br /> QUARTER SECTION(check one): =JE NW SE SW <br /> QUARTER/QUARTER SECTION(check one): F-1 NE F71 NW [-7,L SE SW <br /> 1313 Sherman Street, Room 215,Denver,CO80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br /> 4 <br /> 1876% <br />