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<br />_t <br /> <br />LIMITED IMPACT OPERATION (110)~L -~ <br />APPLICATION FORM ~ i i± ~ ','~~~') <br />This form contains two major parts: (1) General Operation Information and (2) Exhibits <br />A-G. When you submit your application, be sure to include akb.~s't`ned copies of the <br />General Operation Information, two copies of Exhibits A-G, and a c e k for the <br />application fee described under (4) below. To expedite processing, please provide the <br />information in the format and order described in this form_-ry~_1.2g1=a~__C3'i~5.~--Q~^~~~~y <br />GENERAL OPERATION INFORMATION ""'~" <br />Type or print clearly, in the space provided, all information described below. <br />1. Applicant/Operator Name: Jeanette Yaklich& Edward M. Yaklich <br />2, Operation Name (Pit, mine or site name): shangri la Pit <br />3, Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* 9.9 permitted acres. <br />(E10 x (affected acres) + E25.00).* <br />Note perritted acreage and application fee and <br />attach a check for this amount when you file. $125.00 application fee. <br />5. Substance(s) to be mined (e. g., gold/silver/gravel): gravel ~ <br />6. Owners(s) of Substance to be E4ined <br />(checE; applicable box(s)): ® Private ^ State ^ Federal ^ Indian <br />7. Owner(s) of Record of Affected Land <br />(checl: applicable box(s)): ^ Private ^ State ^ Federal ^ Indian <br />8. Type of I~ining Operation <br />(check applicable box(s)): [J Surface ^ Underground ^ In-situ <br />9. Location Information. The center of the area where the majority of mining will <br />occur liE~s in: <br />COUNTY: Custer <br />PRIIICIPLE MERIDIAN check one ® 6th (Colorado) ^ 10th (New Mexico)^ Ute <br />TOWNSHIP (write number and check direction): T 22 ^ North ® South <br />RANGE (write number and check direction): R 72 ^ East ® West <br />SECTION (write number): S 30 <br />QUAE(TER SECTION (check one): ^~- ® NW ^ SE ^ SW <br />QUAE(TER/QUARTER SECTION (check one): ^ NE ^ NW ^ SE ® SW <br />GENERAL DESCRIPTION: <br />(miles and direction 2z miles southwest of Westc liffe, CO. <br />from nearest town and _ <br />approximate elevation) elevation 7800' . <br />* If the operator is a unit of State or county government, an application fee is not <br />required. A fraction of an acre must be counted as one acre for fee calculation. <br />