PERMFILE114729

• Permit No: M2004021
• IBM Index Class Name: Permit File
• Doc Date: 3/22/2004
• Doc Name: 112c Appl
• From: Washington County
• To: DMG
• Media Type: D
• Archive: No

Certification.
As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements
of the following terms and conditions:
1. To the best of my lmowledge, all significant, valuable and permanent man-made shucture(s) in existence at the time this
application is filed, and located within 200 feet of [he proposed affected azea have been identified in this application
(Section 34-325-1 li(4)(e), C.RS.).
2. No mining operation will be located on lands where such operations aze prohibited by law (Section 34-32~-1 I~(4)(f),
C.RS.;
3. As the applicant/operator, I do not have any extraction exploration operations in the State of Colorado currently in
violation of the provisions of the Colorado Land ReLlamation Act for the Extraction of Construction Materials (Secticn
34-32.5-120, C.RS.) as determined through a Boazd finding.
4. I understand that statements in the application are being made under penalty of perjury and that false statements made
herein aze punishable as a Class 1 misdemeanor pursuant to Section 18-8-503, C.RS.
t~
Signed and dated this ~ day of /)'f~Lff .ADO ~~:: ".'` ~..` '%~
._, v J •-
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Washington County Road and Bridge District lfl IfGorporationAttest,(Seal)•~,
A IicanU erator or Com an Name ; ^ •
PP GP P Y -.'~p • ..... •''-
p /J ~...; . ~ , ~,,n..n
signed: LG(_ --- - ~ signed: ~ n~'~o_'nc1l~ 1~ l nom(
Corporate Secretary or Equivalent
Title: County Commissioner
State of Colttrce~o )
ss
County of (~a.~~,•,„,_y~_)
Town/City/County Clerl:
The foregoing instrument was aclmowledged before me this `dl ,~ day of t~tare~ ay o y _ ,
by ~r~,c2 -Sr~4.v~a~. as eo~~~,.....v~,ss~ons,r of~r"Jc-s4:.,,,~~ean
=o~cagy~ , ~~ ~ ~,~
-~"" Notary Public
A ~G o0
qr ~ B ~ 0.Q. My Commission expires: ~-II -a0a1
SIGNATURES MiJST BE IN BLUE INK