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LIMITED IMPACT OPERATION (110) ~ ~ ~,F (,/F r~ <br />' RECLAMATION PERMIT IJ <br />APPLICATION FORM ~~~~p ~~QQqqCC <br />CHECK ONE: X New Application (Rule 1,4); Conversion Appli'c°a'Lio0n2 (itule I.11) <br />Permit # M (provide for canverei As of exist~n~ its) <br />$wision of ~,~ineia <br />The application fora Limited Impact Designated Mining Operation Reclamation Permit contains <br />three major parts: (1) the application form; (2) 8xhibits A-J, any required sections of <br />Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in <br />Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; and (3) the application fee. When you submit your <br />application, be sure to include one (1) sioned and notarized original and one (1) copy of the <br />application form, two (2) copies of Hxhibite A-J, appropriate sections of 6.4.19 8xhibit S <br />and 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee <br />described under (4) below. Hxhibits should not be bound or in a 3-ring binder; maps should <br />be folded to 8 1/2" X li" or 8 1/2" X 14" size. To expedite processi g, lease provide the <br />information in the format and order described in this form. ~~ _CL-'~/'~~_7 ___-_--_- <br />GENERAL OPHRATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />------------- ---------- <br />i. Applicant/operator or company name (name to be used on permit): <br />~ae Rn^~ and Marlene ~1. Rnth~ <br />1.1 Type of organization (corporation, partnership, etc.): Private Lnndownor <br />1.2 I.R.S. Tax iD No. or Social Security Number: ~ <br />Rothe Sand and Gravel Pit <br />2. Operation name (pit, mine or site name): <br />3. Permitted acreage (new or existing site): g'95 permitted acres <br />3.1 Change in acreage (+ or -) acres <br />4. Fees: <br />4.1 New Application ~ S875.00 application fee <br />4.2 Conversion Fee (from 110d to 110 875.00 conversion fee (Rule 1.11,2(2)) <br />5. Primary commoditie(s) to be mined: Sand and Gravel <br />Same <br />6. Name of owner to the subsurface rights of affected land: <br />7. Name of owner to the surface of affected land; Sama <br />e. Type of mining operation: ~( Surface _ Dnderground _ in-situ <br />9. Location information. The center of the area where the majority of mining will <br />occur lies in: Logan <br />COLiNTY <br />PRINCIPAL MERIDIAN (check one): ~ 6th (Colorado) _ 10th (New Mexico) _ Dte <br />SECTION (write number): S ~~ <br />TOWNSHIP (write number and check direction): T North _ South <br />RANGE (write number and check direction): R ~- ~_ Bast ~ West <br />QIIARTER SECTION (check one): _~NE _ NW _ SE X SW <br />QDARTSR/QIIARTER SECTION (check One): _ NS _ NW ~[ S8 _ SW <br />GHNSRAL DESCRIPTION: (miles and d nearest town and approximate <br />elevation) lhnrnximatali 7~7 mils crn~th of Starlin; f.nlnrnrtn <br />Approximately 3938 ft. per USGS Quad <br />10. Correspondence Information: <br />APPLICANT/OPHRATOR (name, address, and phone of name to be used on permit) <br />Contact's Name: Title: <br />.. _ , <br />Company Name: - <br />street: ~r727 Paeter+y Strut <br />City: SkerLin~g <br />State: Colorado zip Code: 80751 <br />Area Code: 303 Telephone: 522-2281 <br />~~ . <br />~f-1~~~1~1i'1~ <br />