PERMFILE103425

• Permit No: M1987040
• IBM Index Class Name: Permit File
• Doc Date: 3/4/1987
• Doc Name: LIMITED IMPACT OPERATION 110 APPLICATION FORM
• Media Type: D
• Archive: No

~;; ~ •
-2-
10. Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
IndiVidUal'S Name: John T. Ungefug
Company Name: Southway construction co.
Street: iii white Pine
City: plamosa
State: Colorado Zip Code: eiloi
Area Code: 303 Telephone: sa9_-slos
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State: Zip Code: _
Area Code: Telephone:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's (Jame:
Company Name:
Street:
City:
State: Zip Code: _
Area Code: Telephone:
11. Primary future ^ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use ,~ Rangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
(check one): ^ Residential(RS)^ Recreation(RC) ^ Industrial/Commercial(IC)
^ Developed Water Resources(WR) ^ Solid Waste Disposal(WD)
12. Primary present ^ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use QXRangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
(check one): ^ Residential(RS) ^ Recreation(RC) ^ Industrial/Commercial(1C)
^ Developed Water Resources(WR)
To the best of my knowledge, all the information presented on this application form and
the attached Exhibits A-G are true and correct (must be signed by applicant/operator).
Date: ~~7 ~~7 BY: ~~a,e¢
~~C6 -- ~6 S
T~~e