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V <br /> • COLORADO <br /> • <br /> Division of Reclamation, r "*C:E1 /` 0 <br /> Mining and Safety <br /> T FEB 0 4 2021 <br /> D,.;,.t,. CO 80;0; L)MSION OF <br /> MINING AND RECLAMATION <br /> LIMITED 1MPACTOPERATION(110(1)) <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> C'l1LCK ONE: New Application <br /> Permit 9 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;aW(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 19t be bound or in a 3-nng binder,maps should be folded to 8 1;2" X <br /> 11"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 clearh,in the space provided,all information described below <br /> 1. Applicant/operator or company name(name to be used on the permit): Jeff A Carter <br /> 1.1 Type of organization(corporation,partnership,etc.): Individual <br /> 2 Operatiog name(nit,mine or site name); Lombard#3 <br /> 3 Permitted acreage(new or existing):(must be 5 acres or less) 2 permitted acres <br /> 4 am <br /> 4.1 New Application S288,00 application fee <br /> 5. Primary commodities)to be mined. Gold &Silver <br /> 6. :Name of owner to the surface of affected land: US Forest Service <br /> 7. ;Name of owner to the subsurface rights of affected land: US Forest Service <br /> 8. Type of mining operation: _a Surface i • i Underground nPlacer <br /> J s4 <br /> 1313 Sherman Street,Room 215,Denver,CO 80203 P 303.966.3567 F 303.832.8106 http://Mining.state.co.U$ <br />