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,r <br />T <br />6. NAMES AND ADDRESSES OF ADJOINING PROPERTY OWNERS, LESSEES, ETC., WHOSE PROPERTY ALSO ADJOINS THE WATERWAY <br />west Elk Coal Calgaany <br />6. WATERBODV AND LOCATION ON WATE RBODV WHERE 4CTIVITV E%1373 OR IS PROPOSED <br />North Fork (~ulnison River <br />Citnni son County, Colorado <br />7. LOCATION ON LAND WHERE ACTIVITY E%1575 OR IS PROPOSED <br />ADDRESS: Pdjao2nt to Highway 133 approximately 1 mile east of the town of Sarerset. <br />STREET, ROAD, ROUTE OR OTHER DESCRIPTIVE LOCATION <br />(~uulison Colorado 81434 9 135 90W <br />Sae. Ttvp. <br />COUNTY STATE ZIP CODE Tae Aflaaapfa ~alCripljpq; <br />(~uulison County (M+o N~_- ---~~ ~~ <br />LOCAL GOVERNING BODY WITH JURISDICTION OVER SITE ~~~~' fi~Na <br />B. b enY Partipn of tM eeilvltY for which euthonxrtion it mupht now cbm PNte7 ^ V ES ^ NO <br />If enrwer le "YM" plve reeepm, month •nd YYI the ec\wity wer cOmpletetl. Indcete the en~Rina work On the tlreWinpe. <br />9. Lirt UI ePDroveb pr esrtl}lutlOne entl tlenbb r~Nivetl from other Ntlwel, inNrRe\e. cteie or loeel epMCib fo1 env rtructurm, eOnemuctlOn, <br />OlKherpm or Other eetlvltlN tleecribed in Ihie epPllcetion. <br />ISSUING AGENCY TYPE APPROVAL IDENTIFICATION NO. DATE OF APPLICATION DATE OF APPROVAL DATE OF DENIAL <br />10. APPIIGtIPn le hereby merle for • pwmlt pr permlte to euthbrl[e the eRirltim derellbetl hweln. I <wtlfY that I em fem1141 wlth the In}OlmetbR fOMal[md In <br />thle ePPllntlOn, end that t0 the beR bf mY knbwletlpe entl belle} such IntormetlOn le rue, ebmPlKe, entl ecculem. I furthw ewtlfY tllet 1 primer the <br />euthOrltY t0 undelmk• She Ara POetl eRlYltlm a1 I em eRlnp ee the duly euthOrirb eaeni Of the eppllunt. <br />~ cJ <br />IONATURE OF APPLICA DATE SIONATU RE OF AGENT ~ DATE <br />The application mrut 6t signed by the person who desires to undertakt tht proposed activity (appfiednt) or it may 6t signed by d duly <br />Authorized argent i/the statement in Block 3 has been Jilkd out and signed. <br />18 U.S.C. Section 1001 providm that: Whoever, in any manner within the jurisdiMion o[ any department or sgency of The United 94tH <br />k nowirgly snd willfully falsifies, Lnnttsb, or covers up by sny trick, scheme, or devitt a metvul [aM or mskes any (Ilse, Tictitiotu m <br />fraudulent sutemen4 or reprcmntations or makes or uses sny false writing or document knowing mme to rnntain any false,fictitiotu or <br />fraudulent statement or entry, shell be fined not more than 510,000 or imprisoned not more than five yeas, or both. <br />Do not send a permit prottming fee with this application. The appropriate fee will be assessed when ^ permit is imued. <br />