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-~~- <br />rrgm~lo-1 ]tN1TED STA' ( ' <br />(October 1975) DEPAI T OF TH III IIIIIIIIIIIII III \ FORM APPROVED <br />` I OMB NO. 42-R0875 <br />BUREAU l~. LAND MA. _. _ 9J9 t Parma nr„mt,.. <br /> <br />- FREE USE APPLICATION AND PERMIT Expiration Date <br /> t ~~~` I t <br />VEGETATIVE OR MINERAL MATERIAL . <br />District <br />APPLICATION rr..:.. <br />Name of applicant Q Address (include zip code) <br />"~FF'AT COffiv~~ RG`rL^ DEPT. } BO <br />R <br /> CR4IG <br />COLC <br />ADO 81625 <br />Kind of material Estimated quantity -~_;r~~ <br />CRTrTrar, GnltrrI 5f'7 vr)s v a <br />Give legal land description . <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />T12n R9+t': t3 LOTS 1d:$ <br />T12N R93t~ 18 LOTS ~+rtOf: NORTn PORTION OF LOT 11 <br />REQITEST . 0? R.~.I•:N':AL APPLICATION FOR FIB E YEARS y~ 20 <br />.S.>-,,~ %~i ~ <br />Materials are to be used for <br />SURFACE FOR CCLTNTY RO,;iJS <br />I HEREBY AGREE TO COMPLY WITH the special conditions as set forth below. I CERTIFY That the: (a) materiels <br />to be removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bazteced; <br />(c) removal of materials can begin only upon receipt of ar. approved copy of this permit; and, (d) the authorized o[ficer <br />is to be notified upon completion of removal. ~~ <br />I CERTIFY That I am twenty-one years of age or older, a citizen of the United ~ States, and resident of the Ste;e of <br /> <br />I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best <br />of my knowledge and belief and are made in good faith. ~ ~~ <br />' <br />/~ <br />- <br />,ray;. 25. i a?~ ~ <br />!i <br />,~ <br />i <br />(Date) ~ ~ ~ (Si etUre of Applicant) - <br />• <br />Title 18 U.S.C. Section 1001, makes it a crime for any Derson knowingly end willfully to make to any department or agency a[ the ~. <br />United States any [else, fictitious, or fraudulent statements or reDres entet ions as to any matter within ita jurisdiction. _ ~ ~ ~`.fa. <br />~l~ <br />_ . PERMIT r: ; r•~!r - . a. <br />,n, - ' ~.. <br />•~ ~ ~ SPECIAL CONDITIONS - -` -~ ~g'.~T,r.~~'?~';';• <br />~ , <br />, <br />4C.. <br />This permit is hereby issued for the materials applied for but may be canceled jf it appears that this permit was"' <br />~ <br />issued erroneously or the terms or conditions contained herein are not observed. It shall be subject to the following~+A <br />',~' <br />special conditions: .. '. <br />51:Ni Ail At:fi t.h Ll a'1' _ '~' <br /> <br /> <br />a i , <br />~, <br />.. <br />r ~ ~ <br />~~ <br />. <br />Conservation practices must be practiced es provided The permittee shall clean up all work areas and shall <br />by 43 CFR 5511.1-1(b), .2-3(c), and .3-3; ,~ <br />1 remove or dispose of all refuse resulting from [he ~' <br />tt <br />Equipment, personal property, and improve ~ nts mtut permittee's operations; ~ .. <br />~ <br />be removed within ninety (90) days after` expiration <br />~ <br />date (43 CFR 3621.4(c) or 5511.3-5); t This permit is issued under the Act of July 31, 1947, <br />f as amended, and 43 U.S.C. 2 and 1201. <br />Any use of the surface of the lands involved in this <br />permit shall be such as not to interfere with any mining <br />claim subject to the provisions of Section~4 of the Act ~ `- <br />55 (30 U.S.C. 613); <br />of July 23, 19 <br />/ <br />Z/~/ ~~_ <br />ate) (Signatur o Authorized Officer) <br />• G-o sor-aU ~ GPPI ICCNT <br />