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COLORADO RECEIVED <br /> A&7 Division of Reclamation, <br /> Mining and Safety AUG 1 5 2019 <br /> C_oartm.._7.t of TJ2`,iral�eso_., <br /> 1313 Sherman Street, Room 711 <br /> DIVISION OF RE=WTION <br /> Denver, CO 80201 MINM AND SAFETY <br /> LIMITED IMPACT OPERATION(110(1)) <br /> RECLAMATION PERMIT 1 <br /> APPLICATION FORM <br /> CHECK ONE: _a Ne p ication <br /> Permit M- - 0 1 -© (pr ide for conversions and amendments of existing permits) <br /> t' a Li mite inin Operation Reclamation Permit contains three major arts: 1 the application form; <br /> The application for im g p J p O pp <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 /> I I"or 8 1/2"X 14"size. To expedite processing,please provide the information in the format and order described in this fonn. <br /> GENERAL OPERATION INFORMATION <br /> Type or print clearly,in the space provided,all information described below <br /> 1. Applicant/operator or companv name(name to be used on the permit): rJ <br /> 1.1 Type of organization(corporation,partnership, etc.): L/,— 0 <br /> 2. Operation name(pit, mine or site name): i,� 13 le <br /> 3. Permitted acreage(new or existing): (must be 5 acres or less) ' pennitted acres <br /> 4. Fees: <br /> 4.1 New Application n / $288.00 application fee <br /> 5. Primary commodities)to be mined: �' e ( '_f V <br /> 6. Name of owner to the surface of affected land: ; I� <br /> 7. Name of owner to the subsurface rights of affected land: �� ;tiTQ l2 K <br /> 8. Type of mining operation: Surface CL Underground F]Placer <br /> 6F:coir . <br /> 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us I'*i <br />