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1 <br />~:,al r• <br />Form 5510-1 <br />(March 1988) <br /> <br />~^ <br />~- <br />~~. <br />UNITED STATES ' <br />DEPARTMENT OF THE INTERIOR <br />. BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL ' <br />APPLICATION <br />FORM APPROVED <br />Oh1B N0. 1004-0001 <br />Expires: October Jl, 1990 <br />Permit Number ~. ~ . <br />- GOC-52699 <br />Expiration Dam ~ .".,^j~f5"~'~'.:,;::.', `-. <br />April 1. 1996 <br /> <br />Name of applicant ~ ~ ~ ~. ~. .~. ~ ~ .. ,. ~ Address finefude zip code) ~. ~ .. ~ ~ ~ - <br />Ouray County, Colorado PO Sox C, Our.a:a, Colorado 81427 <br />Kind of material Sdnd and Cra¢el ~ ~ ~ ~ .~ .. ~ ~ ~ Estimated quantity20, 000 ydS/VEE? <br />Give legal land description ~ ~ ~ ~ - - <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />.. ~ : , <br />.. .: <br />T.45N:, R.8W.;-Sec: 3, E~NW}NW} an3 WkNE}N1J}, NMPM <br />State of, Colorado CanntyoC Ouray ". <br />Materials arc to be used for <br />-.~,, ..... ~c.-I n~c~.-.... -, ...1 ~..1 .. ~.t ..rA <br />1 HEREBY AGREE TO COMPLY WITH the special conditions as set forth below. I CERTIFY That the: (a) materials to be removed arc lobe used for the purpose noted <br />above; (b) none~of the materials removed arc to b<sold or bartered; (e) removal of materials can begin only upon receipt of an approved copy o(this permit; and, (d) the <br />authorized officer is to be notified upon Completion of removal. <br />1 CERTIFY That 1 am a citizen of the United States, and of the age o[ majority in the State in which 1 reside. <br />1 FURTHER CERTIFY That the statements made by me in this application arc true, complete, and correct to the best of my knowledge and belief and are made in good <br />faith. - <br />(Date) (Signature of Applicant) <br />' Title lB U.S.C. geesion 1001, makes itaerimefor any person knowingly and willfully to maketo any department or agency of the United Stains any false, Ectisious, orfraudulentsusements or <br />repre:emmions as to any mattec within its jurisdiction. <br />PERMIT <br />' SPECIAL CONDITIONS <br />This permit is hereby issued [or the materials applied for but may be canceled if it appears that this permit was issued erroneously or [he terms or conditions contained <br />herein arc not observed. It shall be subject to the following spccial~eonditions: ~ ~ , <br />' ' ATTACHED . <br />Information is collected to Comply with Statutes (16 U.S.C. 60406 and agency Regulations (43 CFR 5311.1-I(f)). <br />Information is used to confirm the residence of the applicant. <br />Applicant mutt respond to obtain a permit. ~ ~ ~ ~ ~ ~~ <br />' Conservation practiecs mutt be carried ous as provided by 43 CFR 3511.1-I(b), .2-7(c), The permissee shall clean up all work Gress and shall remove or dispose of all refuse <br />.and .3-3: resulting from the permittee's operations:. <br />Equipment, personal property,and improvements mrvr b<rpmoved within ninety (90) 'This permit is issued under the Act of3uly 71, 1917, u amended, and 43 U.S.C. and <br />' days after expiration dart 43 CFR 5511.3-5); .' _ 1701, and under the free use privilege of sht Act of play 14, 1898 (Alazka only). <br />Any use of the Surface of the lands involved in this permu shall b< such as not to An annual mponindicating tbtamount (cu.yds. or tons) of material removed must be <br />inlerlere wish an}'mining claim subject cache provisions of Secsion4 of the Act of July filed with the District Offi<e on the anniversary dale of the permit, or within thirty l30J <br />23, 1955 (70 U.S.C. 613); . ~ days after Pcrmit expiration (Alaska only). <br />-. r :' <br />.. <br />