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/' <br />999 <br />LIMITED IMPACT OPERATION (110(2)) <br />~~~ "'~, <br />~.. ~' d <br />aPR 13 i9~3U <br />APPLICATION FORM t~jCJ~D L':t~C. <br />The Application fora Limited Impact Operation Reclamation Permit-contains three major <br />parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the <br />application fee. When you submit your Application, be sure to include two si~n~e~d copies <br />of the Application Form, two copies of Exhibits A-F, and a check for the appTi-c~fon fee <br />described under (4) below. To expedite processing. please provide the information in <br />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 />---------------=------------ - -------- --------- <br />1. Applicant/Operator Name: Fremont County Board of County Commissioners <br />2. Operation Name (Pit, mine or site name): Qna4,,,ire Creek nit <br />3. Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* 2.73 permitted acres. <br />(=10 x (affected acres) + 525.00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. N/A application fee. <br />5. Substance (s) to be mined (e.g., gold/silver/gravel): travel <br />6. Owners (s) of Substance to be Mined <br />(check applicable box(s)): _ Private _ State ~71X Federal _ Indian <br />7. Owner(s) of Record of Affected Land <br />(check applicable box(s)): _ Private _ State y~ Federal _ Indian <br />8. Type of Mining Operation <br />(check applicable box (s )): Surface _ Underground _ In-situ <br />9. Location Information. The center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: <br />PRINCIPLE E A~ c ecc one 6th (Colorado) <br />10th <br />(New Mexico) Ute <br />TOWNSHIP (write number and check din ion): T 49 xx North South <br />RANGE (write number and check direction): R 11 xx East _- West <br />SECTION (write number): S <br />~ <br />QUARTER SECTION (check one): ~ NW SE SW <br />QUARTER/QUARTER SECTION (check one): ~ NE = NW _ SE _ SW <br />GENERAL DESCRIPTION: <br />(miles and direction Annrnx~_ i~a tg]~ 17 milna Nnrth of Cotnnaxi on <br />from nearest town and <br />approximate e]evation) th a t 'da f F f_ Rnad !!12 Rlavatinn_Q ?OO ft. <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 />