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<br />Form 5510-] ITED STATES
<br />(Noremher 1976) DEPARTMENT OF THE 1NTERlOR
<br />BUREAU CIF LAND MANAGEh1ENT
<br />
<br />FREE USE APPLICATION AND PERMI'f~;
<br />V EGETATIVE_ OR MINERAL MATERIAL
<br />ADDI 1!-A Tlr,a
<br />Name ofapplicant~ ~ - ~ - -
<br />'Jesa County P,oad 1JeDartrlent •
<br />er /Ii.~ /~~~~
<br />.'r.T.~.., /
<br />-=• -
<br />_ .,
<br />Kind o[ material .- Estimated quantity -
<br />,~oreniae Toad Sa[e'c'r ^ --- - ..~.
<br />~n -1~n Yds
<br />Give legal land description _ - - .. _.
<br />a
<br />State of CO)OradO .. .-.:r-•c._-.~_-.: County..°.f-v,i:~.{/o - ~--
<br />- lY_Sa' r%JCr9
<br />r I I JVnLI VIJIVrv
<br />751Fi. 819:1 -' ~- lb ~ SC4 SIB - - <.
<br />'Jet: ''~exico Frincipai ',Meridian -
<br />Materials are to be used [or - _ ~ ~ - -
<br />I HEREBY AGREE TO COMPLY WITH the special conditions as set Eorth below. I CERTIFY That the: (a) materials
<br />to be removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bartered;
<br />(c)removal of materials can begin only upon receipt of an approved copy of this permit; and, (d) the authorized officer
<br />is to be notified upon completion of removal: ' " "'- '' ~' ~ ~ -"
<br />I CERTIFY That i am twenty-one years of age or older, a citizen of the United States, and resident of the Slate of
<br />I FURTHER CERTIFY That the stltlements made by me in this application are true, complete, end correct to the best
<br />of my knowledge and belief and are made in good faith. -,; ,-,- ~ _.. r•, ,:Y-z.,,.~ (Tj
<br />4. .- ~ _ ,.,,,~- ~.:,,.::_ 9:: r~ :., _--- f~esa C~ nfy`Road Department- --
<br />• ~ ~ ~J.~~ ~.q~:.~n:r:,sioiv-rJ 1=~a~~.~ri, r.~ ~j~~•~Q,J1`J~~3~"1.~i~.. _ ~~~RDati~~~$UDeTVLSOr
<br />(Date) .°-''>E ~.sirn .,csc,iis~!i;~~ .vr,~;a s: :-, rrr:..:: (Signature o[ Applicant) -. -
<br />Title 18 V.S.C. Section .1001',-msk`es it a 'crime "for any person knowingly and willfully to'make to any department or agenry of the . ~ -
<br />United States any false, (ictiti our:~:ni fraudulent statemrnts or representations as:to any-matter within its jurisdiction. ~ s~=r .-: '^
<br />' S:iIIClo^.JyILT 5~7 of N' -•~?. "9rC} 7J ld^Da _.erSF,r 4'.^i°'!' -~'~ ,.•,o. _
<br />~- - .... PERMIT ._ ::. '...~`.,: • :, -...__-..~: _ n: ~ __
<br />- ~ ~ ~ -=F>i .alto ,e:: :c:r. SPECIAL.GONDITlONS ::a:a ~r.'id~ '~~ ~ ~ ~`-wT °a. ..~•.~.
<br />', This permit is hereby jssued~for,t}le„materials-applied .for but may be canceled .if it appears that this permit was
<br />issued erroneously or the terms orc:onditions contained herein are not observed. It shall be subject to the following
<br />' special Conditions:- . =•JOC ab :-os 9I -iS~IT:.anRC=+.~i c,.+ti::'v0~=: T~~' ~~,'.".tssia:-,_~c~ ;.:~~: ..:,:':=Y: .
<br />' ~ - _ -•:~-/'.'' .h0¢.`„x!gg6 V'O~„EfiOti ~; h Y•..•p^S rXY..IuQ J1R 'RL~'.E:\~+-L-. W2~"., .. ., ~•"' + -~
<br />- - ~ Attachet3 as'"E_xhibit.A".,..consisting -of_Tiro°pages=off- ib st~~ulat_ions;_ ; ~'
<br />. = ~'a-'tet3 Dctober$,'1980. :~-. -. - -- s •. - -_'_r.-~t..r ~~,r• _- -
<br />_ F', ~ .
<br />_ _ r ~ .. s. _ .. _ ~ i 'yam. .: l'
<br />^.:.- J ?}, `'~ r''.~ •. - _ - - .-.. fir- ~- •y....-z•-~~
<br />'''jjj . ~ N', r. y -
<br />-1 ' _ ~ .. -.; ~~r'. - - „ Tom. `_ i'. ;:'
<br />. .. i - _
<br />• '. - . _• .. - :-- :. ~ v' :.4 ..ri : '- - 1 ~ _ y'4.. '• ~j . fig -
<br />' a _ Y_66
<br />~l . 1.}~.- Ix ~ c r .- '.
<br />1.':f:ic. .v`•.:=;_., _j.~-_ ,.L .J.,-_ __ - 1 r ,; ~,'.~i. ''f _ 3-;.; :.•^~~i-:-'s-•";f'.Ft.
<br />~• Conservatioq_pcactices must be pt,acticed,.as provide - .The pecmtttee shall deco up ell wock areas and shall -
<br />~ rY4a., Y,. _... r-. r. air r' - d v. +d aF' ~ ~ .
<br />by 43 CFR 55111 1(b), .2~(c)~ end;3-3; , .r;FV ~ - -remove of dispose,-.-of ~_all- re{use. resulting '''from the~;:_
<br />..~ ~ '..~.' i r_.~- ?ti•~:AY y/ ~T ~ti-~..: _::a~.r.i. .; ^' bw~vY.~~--, :rf~;.< - '--. ~-__
<br />. _ •Y' o.. °oa•``-¢' ,.~ +~ ~` . ~ ,rR``'- rmittee s o rations• • r • ~,.. -. ,
<br />~ •Eq~ pme~t, _person~property`, and4mpcovements-must) ~~~•~~ _ifi ~~ <.~~Jr ;,~:! ,~~ar:r~ - r
<br />_ ~,. y O. ys - .. p ate',-..•.,~ -.., •:
<br />• be removed -within nmet 90 'iiir ~aftei ex iratioa„ - ~,. .-+ ,Pt,=:±,~.$'.: ,r..~.r':{~i.
<br />'~ . ~ate-,t43-CFR3621:4(~ yr ~51i3-E);c:' sri~-~' This permit is issued under the Ad:of my 31,.1947,:,. ;.
<br />!~s}+?•y,:- ' `, aya?;+'r ,,., ~- ~i_ as emended,•and. 43•i1:S.`C?2 and 1201. `~• %~'•
<br />"'Any use of 3he'surfece~• the nds3nvo7ved'.~n this'. '~}1.':=1='~'•:'"t5~+=~~,.t~.'!':`'/~,~:-~F .-M'~1~.~ .'•~-r:4
<br />' "-'~^'~yD ' " - - -"' ~`" -An annual report jndicatiog the amount (cu: yd_s. or tons) -`
<br />-:permit"shell be such es not to interfere with any mining ~_ - - -. ~.
<br />claim subject to~ihe provisions of Section 4 o_f the Ac_t o[ mateiiel removed ~mus7. be_ filed with ,the dis-;.
<br />~ofJuly.23, 1955 (30 U;S.C:'613);. - .. trict office, o[ the anniversary date of _the permit, -or ,:.
<br />a + r ~
<br />Jr"~ . ~.. .a ~-}* ° _ ..,,:~':" ~ within tbirry'1~0) days a/tar permit expiration: r~ ~ -
<br />J ^~aly i~s'~e,)r_t`` ~., ~ •`.~^_~.. ,~~J ~~ !/j~JtJ/J~J _- X .•r • .4' ~.,•~r-~-1 _!n i
<br />' (Date)'• •r :.? ~ w=-~ ~ a ~~:' ~~ -y::~• ,~--5 ~ (Sigr,aiure of Aul rorized Officer) - -i `-
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<br />FORM APPROVED
<br />OMB NO. 42-RO875
<br />rermrt rvumtxr
<br />^.~-~7~~
<br />- - Expiration Date'
<br />Address (include zip code') - ~ ~~-
<br />_ - _ Fost.Office Box _1237
<br />~- : - urand J~.Inction. CO P.15f11
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