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<br />STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Department of Natural Resources RECEIVE <br />7 37 3 Sherman St, Room z t s C O L O RA D O <br />Denver, Colorado 80203 D[ v[ s[ o N o r <br />Phone: (303) 8663567 CONSTRUCTION MATERIALS UUN ~ $ 2004 M I N S RRA L S <br />FAX: (303) 832-8106 G E O L O G Y <br />LIMTI'EDIlYIPACT(110)OPERATION OivisionoiMinerals&Ge to®«LANATION•NINING <br />SAFETY•SCIENCE <br />RECLAMATION PERMIT APPLICATION FORM <br />CHECK ONE: There i+ a File Number Already Assigned to this Operation <br />Permit # M -_ _ _ (Please reference the file number currently assigned to this operation) <br />XX New Application (Rule 1.4.5) <br />Amendment Application (Rule ].]0) <br />Conversion Application (Rule 1.11) <br />Permit # M -_ -_ (provide for Amendments and Conversions of existing permits) <br />Bill Owens <br />Governor <br />Greg E. Walther <br />Executive Director <br />Ronald W. Catlany <br />Division Director <br />Natural Resource Trustee <br />The application for a Construction Materials Limited Impact (110) Operation Reclamation Permit contains throe majorparts: (1) the application <br />form; (2) Exhibits A-J, Exhibit L, Addendum 1, any sections of Exhibit 6.5 and Geotechnical Stability Exhibit, as required by the Office, and <br />outlined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); and (3) the application fee. When you submit your application, be sure to include one <br />(I) complete sieved and notarized IVORY ORIGINAL and one (1) copy of the completed I~ application form, two (2) copies of Exhibits <br />A-J, Exhibit L, Addendum 1, and appropriate sections of 6.5 (Geotechnical SiabiGty Exhibit), as required, and a check for the application fee <br />described under (4) below. Exhibits should NOT be bound or in a 3-ring binder, maps should be folded to 8 1/2" X 11" or 81/2" X 14" size. <br />To expedite processing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print ckady, in the apace provided, ALL information described bebw. <br />1. ADDlicanUocerator or comosnv name (name to be used on tsermkl: John M. Everit t <br />1.1 Type of organization (corporation, partrtership, etc.): Individual <br />1.2 1.2 I.R.S. Tax ID No. or Social Security Number: <br />2. Oceratian name (nit, mine or site Hamel: Everitt Pit <br />3. Permitted aceage (new or etcistintr sitel: 9.9 permitted acres <br />3.1 Change in acreage (+) Cs~~ ~ acres <br />3.2 Total Acreage in Permit Area ~u~/,/ q . 9 acres <br />4. Fees: ~. n~- /~~1 2~jr~7 <br />4. ] New Application: l v /)~y~6 $1.094.00 application fee <br />Amendment Fee (C.R.S. 34-32.5-125(II)): ~ ~ Y 719.00 application fee <br />4.2 Conversion Fee (from 110d to 110 $875.00 conversion fee (Rule 1.11.2(2)) <br />5. Primary rnmmoditie(s) to be mined: Gravel <br />5.1 Incidental commoditie(s) to be mined: 1. / Ibs/Tons/vr 2. / Ibs/fons/vr 3. / lbs/Tons/vr <br />4. / Ibs/fonslvr 5. ! Ibsll'ons/vr <br />5.2 Anticipated end use of primary commoditie(s)tobemined: Aggregate for concrete <br />Anticipated end use of incidental commoditie(s) to be mined: <br />Office of Office of Colorado <br />Mined Land Rxlamatilm Active and lrtactive Mines Geological Survey <br />