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COLORADO �I��® <br /> Division of Reclamation, <br /> ., Mining and Safety f�') JUN 0 <br /> Department of Natural Resources (,,l <br /> 1313 Sherman Street, Room 215 Chao- OF RKL ATION <br /> Denver,CO 80203 AND`AF M <br /> LIMITED IMPACT OPERATION(110(1)) >�Sroqll Me <br /> RECLAMATION PERMIT 4- P )CS <br /> APPLICATION FORM <br /> CHECK ONE: _a New Application <br /> Permit#M- - (provide for conversions and amendments of existing permits) <br /> The application for a Limited Impact l 10(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 6.1, <br /> 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 original <br /> and one(1)copy of the application form,two(2)copies of Exhibits A-J,and 6.5{Geotechnical Stability Exhibit),as required,and a check <br /> 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 1/2"X <br /> 1 I"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 /> 'i. <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): ✓ I �V e U,V► c-i <br /> 1.1 Type of organization(corporation,partnership,etc.): 1n d l V 6 du t k <br /> 2. Operation name(pit,mine or site name): __lJ V. l 1 bvl K 1 no <br /> 3. Permitted acreaee(new or existing): (must be 5 acres or less) • OrL permitted acres <br /> 4. Fees: <br /> 4.1 New Application $288.00 application fee <br /> 5. Primary commoditie(s)to be mined: N Q,yG <br /> 6. Name of owner to the surface of affected land: J-�VV e, RV,,A e,4/- <br /> 7. Name of owner to the subsurface rights of affected land: %eve I fx— <br /> 8. Type of mining operation: Surface Underground R Placer <br /> of.cow. <br /> 1313 Sherman Street, Room 215, Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br /> a k." <br /> ='�187,16 <br />