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RECEIVE[ <br /> JAN 2 5 2023 <br /> DIVISION OF RECLAMATION, <br /> LIMITED IMPACT OPERATION(110(1)) MINING&SAFETY-MINERALS <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE: RNewApplication c o p u e r s; c d o -' X f r e s P e c t s ;14 s *a M N : n D I i M,; 4 <br /> Permit IQM- 0 3- L'�D�_ (provide for conversions and amendments of existing permits) II <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 /> 6.2,63,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 or 81/2"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): <br /> 1.1 Type of organization(corporation,partnership,etc.): S 0 T c AW_ <br /> 2. Operation name(pit,mine or site name): _a jam; -1- M: A.-Al <br /> 3. Permitted acreage(new or existing):(must be 5 acres or less) _ permitted acres <br /> 4. Fees: <br /> 4.1 New Application rr $288.00 application fee T <br /> 5. Primary commodities)to be milled: 1?Q[ran "Te 4,jA i r,_( S Pt , 4 7 � j ARD Imo,o.� eg'4 r i a/S."r� <br /> 6. Name of owner to the surface of affected land: _ t <br /> 7. Name of owner to the subsurface rights of affected land: R»L, M_ <br /> 8. Type of mining operation: R] Surface EL Underground OPlacer <br /> 1111 Qwwmmn rfraW Rnrwn 711; rkwrx r rn awn; P VP AAA ArA7 F ir12 217 AWK Mtn-//minirm Oat^en nc <br />