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COLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural Resources <br /> 1313 Sherman Street,Room 215 <br /> Denver,CO 80203 <br /> LIMITED IMPACT OPERATION(110(1)) <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE: _a New Application <br /> Permit#M-,&Iq- O (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. AiDWicant/oyerator or company name(name to be used on the permit): JaOeS Qr1o( yVn(� bnlAf n i via <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) I-s I,- permitted acres <br /> 4. Fees: <br /> 4.1 New Application n / I $288.00 application fee <br /> 5. Primary commoditie(s)to be mined: , /fit <br /> 6. Name of owner to the surface of affected land: ! Q-6 G aa-( <br /> 7. Name of owner to the subsurface rights of affected land: -1a"PS an,4 t-I yekLa. �i��ti)y1iY <br /> 8. Type of mining operation: V Surface F-1 Underground F]Placer <br /> of cod <br /> Few .-On <br /> 1313 <br /> 1313 Sherman Street, Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br /> a <br /> k tg nyM`� <br /> *1876�`. <br />