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COLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> ..rl u` .d r�,rt•�ra Rc u. <br /> U't $helnlan Sneet.Room 215 <br /> Demvei Cotorado 8020_ <br /> CONSTRUCTION MATERIALS <br /> SPECIAL OPERATION III(1)(b) <br /> RECLAMATION PERMIT APPLICATION FORM <br /> The application for a Construction Materials Special 1 1 1 Operation Reclamation Permit contains four major parts: (1) the <br /> application form: (2)Exhibits A-L.Addendum 1.and any sections of Exhibit 6.5(Geotechnical Stabilit\ Exhibit).as required <br /> by the Office, and outlined in Rules 6.1.6.2. 6.3. 6.5.and 1.6.2(1)(b). (3)the application fee. (4)the Performance Warranty <br /> and Financial Warranty. <br /> When you submit your application.be sure to include one completed,signed and notarized ORIGINAL and one copy of the <br /> completed application form. two copies of Exhibits A-L. Addendum 1. appropriate sections of Exhibit 6.5 (Geotechnical <br /> Stability Exhibit). as required. a check for the $400.00 application fee. and the fully executed Performance WarrantN and <br /> Financial Warranty. Exhibits should NOT be bound or in 3-ring binders: maps should be folded to 8 '/"X 1 V or 8 !,"X 14" <br /> size To expedite processing.please provide the information in the formal 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): <br /> 1 1 Type of organization(corporation.partnership.etc 1: C C r'r i C <br /> 2. Operation name(pit,mine or site name): C_co�4 � 1 <br /> 3 Permitted acreage.(must be 30 acres or less) J� Permitted Acres <br /> 4 Fees: <br /> 4 1 Ne\N Application $400.00 Application Fee <br /> 5. Primary commodities)to be mined: ter, <br /> 6 Name of owner to the surface of affected land: "cn' C <br /> 7 Name of owner to the subsurface rights of affected land: <br /> 8. Location information: The center of the area where the majoril, of mining will occur- <br /> COUNTY': r '�t ^ .. <br /> PRINCIPAL MERIDIAN(check one) El6th(Colorado) F 10th(NciN Mexico) n Lite <br /> SECTION(wrile number): S 11 <br /> TOWNSHIP(wrrle number and check direction) T l0 E_ North South <br /> RANGE(write number and check direction): R F-1_ East N'csl <br /> QUARTER SECTION (check one). _7 NI, F I_ NW _ SE SVA' <br /> QUARTER/QUARTER SECTION(check one)- E-1 NE F-1— NNV SE �_SNP' <br /> t c c" <br /> J' <br /> 1313 Sherman Street Room,Z15 Ucnvei CO 80203 V 3U3.866 1567 F 303' 832 8106 http• nnntng.s,ile co us <br /> J A <br />