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c o L o 1 RECEIVED <br /> Division of <br /> z-�&7Mining and M2019045 JAN 9 2020 <br /> i uepar�ment oft <br /> lmac DIVISION OF RECLAMATION <br /> Denver, CO 80203 3 Sherman. MINING&SAFETY <br /> LIMITED IMPACT OPERATION (110(1)) <br /> RECLAMATION PERMIT <br /> APPLICATION FORM VS�a <br /> CHECK ONE; New Application <br /> Permit#VI- _.......... (provide for conversions and amendments of existing permits) <br /> The application for a Limited Impact I I0(1) dining Operation Reclamation Permit contains three major parts: (1)the application form; <br /> (2)ExhibitsA-J,any required sections of Exhibit S and Geotechnieal 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 (GCOteehnical 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"siM 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. AQplicantloperator or company name(name to be used on the permit): <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 $288.00 application fee <br /> 5. Primary commoditie(s)to be mined: . ImAzewu I +I r; 2rrv-, <br /> 6. Name of owner to the surface of affected land: l V <br /> ?. lame of owner to the subsurface rights of affected land: . V L (1 <br /> 8. Type of mining operation: J2� Surface El Underground OPlacer <br /> �•oti"co�.. <br /> �+ _ ,'•�.r. 'poi <br /> 1313 Sherman Street, Room 215, Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mintng.state.co.us * . <br />