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COLORADO <br /> Division of Reclamation,Mining and Safety E C IV E D <br /> Department of Natural Resources ff11 C <br /> 1313 Sherman Street, Room 215 L L V 0 <br /> Denver,CO 80203 <br /> DlVlsv C;1 Rrt',L/'IMT10N <br /> LIMITED IMPACT OPERATION(110(1)) FilINI.141G;%KD SA F ET Y <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE: New Application A <br /> Permit#M-ZD 110`i (provide for conversions and amendments of existing permits) <br /> The application for a Limited Impact 110(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 /> 11"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 /> 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): '�V ybtit 5 1-'m ocs <br /> 1.1 Type of organization(corporation,partnership,etc.): <br /> 2. Operation name(pit,mine or site name): \ <br /> 3. Permitted acreage(new or existing): (must be 5 acres or less) permitted acres <br /> 4. Fees: <br /> 4.1 New Application 1 _ $288.00 application fee <br /> - <br /> 5. Primary commoditie(s)to be mined: S �-� -��(��i�-t. �� 1 00 0- 1C <br /> 6. Name of owner to the surface of affected land: f- <br /> 7. Name of owner to the subsurface rights of affected land: �-1 � ,e ��� �i 1 S C��\;lC C <br /> 8. Type of mining operation: F-1 Surface Underground -]Placer <br /> 1313 Sherman Street,Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us * �' <br /> *JR76 j <br />