INSPEC25499

• Permit No: M1990106
• IBM Index Class Name: Inspection
• Doc Name: LIMITED IMPACT OPERATION 110 APPLICATION FORM
• Media Type: D
• Archive: No

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Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: Rnnda Dockter
Company Name: R_R_K. Construction, Inc.
Street: pp Rnx 376
City: Rye,
State: Colorado Zip Code: 81069
Area Code: 719 Telephone: [phone]
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name': Richard Simpson
Company Name: RBK Construction, Inc.
Street: PO Box 376
City: Rye
State: Colorado Zip Code: 81069
Area Code: 719 Telephone: [phone]
INSPECTION CONTACT (if different from applicant/operator above.)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
Telephone:
Zip Code:
il. Primary future ^ CroplandiCR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use O Rangeland(RL) O Forestry(FR) ~ Wildlife Nabitat(WL)
(check one): ^ Residential(RS)O Recreation(RC) ^ Industrial/Commercial(IC)
O Developed Water Resources(HR) ^ Solid Haste Oisposal(WD)
12. Primary present O Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use ^ Rangeland(RL) ^ Forestry(FR} ^ Hildlife Nabitpt(WL)
(check one): ^ Residential(RS) O Recreation(RC) O Industrial/Commercial(IC)
O Developed Water Resources(WR) ~ .
~
To the best of mY knowled ge, all the infonna n p
nted on thi application form and
the attached Exhib
i
ts A-G are true and co ct (must b sig ned by appli ant/operator).
Dat /
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