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295796 06/17/2020 10:27 AM B: 984 P: 605 PERMIT <br /> Page 1 of 44 R $228.00 D $0.00 T $228.00 Clear Creek <br /> • C O L O R A D O <br /> Division of Reclamation, <br /> . Mining an <br /> Department o` M2020-031 <br /> 1313 Shermar I RECEIVE® <br /> Denver,COB( PSH/jle <br /> LIMITED IMPACT OPERATION(110(1)) , <br /> RECLAMATION PERMIT lt ��:1!�EC�.. <br /> APPLICATION FORM <br /> 1Nii,u,i1.;)AiD SAFM <br /> CHECK ONE: New Application -4, // � <br /> Permit#M- - (provide for conversions and amendments of existing permits) <br /> a <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): Salisbury Gladstone LLC <br /> 1.1 Type of organization(corporation,partnership,etc.): LLC <br /> 2. Operation name(pit,mine or site name): Gladstone <br /> T. Permitted acreage(new or existing):(must be 5 acres or less) 4 permitted acres <br /> 4. Fees- <br /> 4.1 New Application $288.00 application fee <br /> 5. Primary commoditie(s)to be mined: Gold &Silver <br /> : Name of owner to the surface of affected land: Harold &Sara Lesser <br /> 7. Name of owner to the subsurface rights of affected land: Harold &Sara Lesser <br /> 8. Type of mining operation: M Surface F-1 Underground Placer <br /> • <br /> 1313 She reet, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br />