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<br />~ ~' ~ NOV 2 2 2004 <br />CONSTRUCTION MATERIALS <br />Dlylsioa of Minerals and Geology <br />REGULAR (112) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM <br />CHECK ONE: There is a File Number Already Assigned to this Operation <br />Permit # Ivy-~- 266 = (Please reference the file number currently assigned to this operation) <br />New Application (Rule 1.4.5) -Amendment Application (Rule 1.10) <br />X Conversion Application (Rule 1.11) <br />~rmit # M -~- 266 (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Regular 112 Operation Reclamation Permit contains three major parts: (1) the application <br />form; (2) Exhibits A-S, Addendum 1, any sections of Exhibit 6.5 (Geotechnical Stability Exhibit; and (3) the application fee. When you <br />submit your application, be sure to include one (1) complete sinned and notarized ORIGINAL and one (1) copy of the completed <br />application form, iwo (2) copies ofExhibits A-S, Addendum 1, appropriate sections of 6.5 (Geotechnical Stability Exhibit, and a check for <br />the application fee described under Section (4) below. Exhibits should NOT be bound or in a 3-ring binder; maps should be folded to <br />8 1/2" X 11" or 8 1/2" X 14" size. To expedite processing, please provide the information in the format and ord er described in this form. <br />GENER.9L OPERATION <br />Type or print clearly, in the space provided, ALL information rer(aested below. <br />I. ApplicanUonerator or company name (name to be used on permitl: JACKSON COUNTY ROAD AND BRIDGE <br />1.1 Type df organization (corporation, pamtership, etc.): COUNTY -LOCAL GOVERNMENT -CORPORATION <br />1.2 LR.S. Tax LD. No. or Sociat Security Number: / <br />2. Operation name (pit, mine or site Hamel: RILEY GRAVEL PIT <br />3. Permitted acreaee (new or esistine site): <br />acres <br />3.l Change in acreage (+) <br />3.2 Total acreage in Permit area <br />4. Fees <br />3.844 permitted <br />15.156 acres <br />19.09 acres <br />4.1 New Application $2.344.00 application fee <br />4.2 New Quarry Application $2.906.00 quazry application <br />4.4 Amendment Fee $1.935.00 amendment fee <br />4.5 Conversion to 112 operation (set by statute) $2.344.00 conversion fee <br />5. Primary commoditie(s) to be mined: SAND GRAVEL <br />S.l Incidental commoditie(s) to be mined: 1. lbs/Tons/vr 2. / ]bs/Tons/vr <br /> 3. / ]bs/Tons/yr 4. / Ibs/Tons/vr 5. / Ibs/Tonslyr <br />5.2 Anticipated end rse of primary commoditie{s) to be mined: County road surfacingand construction. <br />5.3 Anticipated nd nse of incidental commoditie(s) to be mined: _. <br />