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, C O L O R A D O <br /> Division of Reclamation, <br /> Mining and Safety <br /> i <br /> I Departrae;it of Natural Resources <br /> 1313 Sherman Street, Room 215 ��` �'e� �e i" <br /> Denver, CO 80203 <br /> LIMITED IMPACT OPERATION (110(1)) <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE: New Application <br /> Permit#M- - (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 /> 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): ;�lKktM �� r M�1Jr� <br /> 1.1 Type of organization(corporation,partner-ship,etc.): <br /> 2. Operation name(pit, mine or site name): c� �S V � 1,� � I— <br /> T "T <br /> 3. Permitted acreage(new or existing): (must be 5 acres or less) CC permitted acres <br /> 4. Fees: <br /> 4.1 New Application $288.00 application fee <br /> 5. Primary commodities)to be mined: <br /> 6. Name of owner to the surface of affected land: �,� ram[ _ ' —��K % OCE <br /> 7. Name of owner to the subsurface rights of affected land: <br /> 8. Type of mining operation: Surface F-1 Underground Placer <br /> �O Cpj��, <br /> 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br /> �87 <br />