PERMFILE117201

• Permit No: M1995063
• IBM Index Class Name: Permit File
• Doc Date: 8/2/1995
• Doc Name: LIMITED IMPACT OPERATION RECLAMATION PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

-z-
PfiRlII1TING CONTACT (if different from a li / rotor above)
~~tA~PR
CA~lT
Individual's Name: /
SAME AS APPLI
- Title:
Cca~any Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
INSPECTION CONTACT
individual's xame: SAMF AS APPLICANT/OPERATOR
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephcne:
CC: STATB OR F®ERAL LANDOWNER (if amr) NONE
Agency:
Street:
City:
State: Zip Code:
Area Code: Telephone:
CC_ STATE OR FBDfiRAL LAiIDOWNfiR (if arrv)
Ageaay: N()N E
Street:
City:
State: Zip Code•
Area Code: Telephone:
11. Primary future (Poet-mining) land use (check one):
Cropland(CR) _ Pasturelaad(PL) General Agriculture(GA)
Raayelaad(RL) _ Foreatry(PR) _ Wildlife Nabitat(WL)
Resideatial(RS) _ Recreatian(RC) Iaduatrial/CO®ercial(IC)
_ Developed Water Reeoureee(WR) _ Solid Waste Dispoeal(WD)
12. Primary nreseIIt load use (c1~ecJc one)
Croplaad(CR) Pasturelaad(PL) General Agriculture(GA)
g Ranyelaad(RL) _ Forestry(FR) _ Wildlife xabitat(WL)
Reeidential(RS) Recreatiaa(RC) Industrial/Commercial(IC)
_ Developed Water Reaources(WR) _ Miaing(Mx)
13. If this aperatian rill use deaigaated chemicals, or rill result, or presently has
acid mine drainage - you cannot use this application form. You moat submit a either
a 110d or 112d application form for Designated Mining Operations. In either cane, -
you must list a~ acidic or taodc-forming materials, exposed or disturbed as a
result of the ~~^~^g operation, sad rhether the operation rill result in or
presently hoe acid mine drainage:
Descriotioa of Conversion:
If you are converting as existing operatien, provide a brief narrative describing the
proposed change(s).
a 6 Exhi~ita:
Submit tro (2)
6.3.1 B~IBIT A
6.3.2 SSBIiBIT 8
6.3.3 SB~IT C
6:3.4 Sa818IT D
6.3.5 822~ZT.8
6.3.6 82~IT P
:amplete, unbound copies of the follooring application exhibits:
- Legal Description and Location Map
- Site Description
- Mining Plan
- Reclamation Plaa
- Maps
- List of Other Pezmita sad Licenses Required