PERMFILE63782

• Permit No: M1978085
• IBM Index Class Name: Permit File
• Doc Date: 2/3/1978
• Doc Name: FREE USE APPLICATION & PERMIT VEGETATIVE OR MINERAL MATERIAL
• Media Type: D
• Archive: No

rrgrrr5nl o-t --UNITED STATES y
(c.'°t°~=' leis) DEPA~~'T OF THE INTERIOR
BUREA LAND MANAGEMENT ,
' ~.
FREE USE APPLICATION AND PERMIT
VEGETATIVE OR MINERAL MATERIAL
APPLICATION
(Jame of applicant 4. Address (include zi;
P'OF? ;,T CGUit:Y ~GA% DAFT. ~ P.C. BOX E
CR4IG. COI
Kind of material
FORM APPROVED
OMB NO. 42-R0825
Permit Numher
Expuetion Date
r
District '
r.. . t ..
code)
Estimated quantity -,.
T12r. R9+4J i3 LOTS 1Fi5
T12N R93W 18 LOTS 4,10E tICRTn PORTION OF LOT i1
RE:~iTFST : GR P,F..ivR::AL AFPLIC,ITIGI] FGR FICn YEARS ~ 20
<- . , )
Materials are to be used for •
STJRFACE FOR CCCri~TY fiOADS
I HEREBY AGREE TO COMPLY WITH the special Conditions as set forth below. I CERTIFY Thet the: (a) materials
to be removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bartered;
(c)removal of materials can begin only upon receipt of ar. approved copy of this permit; and, (d) the authorized officer~~
is to be notified upon completion of removal. ~ ~~-~;~
I CERTIFY That I am twenty-one years of age or older, a citizen of the United States, and resident of the State of
I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best
of my knowledge and belief and are made in good faith.
.;air. 25, X977
(Date)
Title 18 U.S.C. Section 1001, makes it a crime (or any person knowingly end wil](ully to make to any department or agency of the ;~ ,,y
United Ste tes any (else, fictitious, or fraudulent statements or reDres entations es to any matter within its jurisdicllon. _ ~r ~ a
"`. i:.
PERMIT _ . fir, .ri.~,.;c, .~~i
"~~
r- SPECIAL CONDITIONS "'i ~,ir.. ,~t ~ - - '.a~c'~s'
,.. .
This permit is hereby issued [or the materials applied for but may be canceled if it appears that this permit was "'
issued erroneously or the terms or conditions contained herein are not observed. It shall be subject to the following",,~~
special conditions: ~• ~ ~ '

Conservation practices must~be practiced es~ ~rovided
by 43 CFR 5511.1-1(b), .2-3(c), and .3-3;
Equipment, personal property, and improve ~nts must
be removed within ninety (90) days after expiration
date (43 CFR 3621.4(c) or 5511.3-5); r
Any use of the surface of the lands involved in this
permit shall be such as not to interfere with any mining
claim subject to the provisions of Section 4 of the Acl
of July 23, 1955 (30 U.S.C. 613);
-7,--_"'T~~
(Date)
~i;
The permittee shall clean up all work areas and stall ,
remove or dispose of all refuse resulting fiom Mlle
permittee's operations; t
~ ... _
This permit is issued under the Act of July 31, 1947, ~~
es amended, and 43 U.S.C. 2 and 1201.
1: -
Officer)
. c•o ear-ata ~ f APPLICANT