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COLORADO <br /> DiVASio?�of Reclarnax c.i.. <br /> f. <br /> Mining.e--kd Safety <br /> 313 She.nna St.e`t. ^Pnc-2- <br /> .�:�.CO&`TLO3 <br /> LIMITED IMPACT OPERATION(110(1)) <br /> RECLAi IATION PERMIT <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 I I0(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 /> I 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 /> 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): Jacob P Ulrich <br /> I.1 Type of organization(corporation,partnership,etc.): Individual <br /> 2. Operation name(pit, mine or site name): Ulrich- Rovedo Mine <br /> 3. Permitted acreage(new or existing): (must be 5 acres or less) 4.99 permitted acres <br /> 4. Fees: <br /> 4.1 New Application S288.00 application fee <br /> 5. Primary commodities)to be mined: collectable minerals associated with Quartz bearing pegmities <br /> 6. Name of owner to the surface of affected land: USDA- Pike National Forest <br /> 7. Name of owner to the subsurface rights of affected land Jacob P Ulrich and Brent Rovedo <br /> 8. Type of mining operation: Surface n Underground nPlacer <br /> 1313 Sherman Street, Room 215,Denver, CO 80203 P 303.866.3567 F 303.832.8106 ht:tp://mining.state.co.us z <br /> tw-� <br />