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iii iiiiiiiiiiiuiii (,1AR 131989 LIMITED IMPACT OPERATION (110(2)) MlPSE:D L,4F+Id APPLICATION FORM RECLAMATION dl•d18!!7U The Application fora Limited Impact Operation Reclamation Permit contains three major parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the application fee. When you submit your Application, be sure to include two signed copies of the Application Form, two copies of Exhibits A-F, and a check for the application fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. ------------~---------------------------------------m=~~ ~ ______=____________________ GENERAL OPERATION INFORMATION Type or• print clearly, in the space provided, all information described below. 1. AppltCant/OperdtOr Name: San Miguel County Road Department 2. Operation Name (Pit, mine or site name): zaara Zit 3. Application type: Limited Impact Operation (110). 4. Application Fee for Permitted Acreage* permitted acres. Mn (b10 x (affected acres) + E25.00).* Note permitted acreage and application fee and attach a check for this amount when you file. application fee. 5. Substance(s) to be mined (e.g., gold/silver/gravel): Cravel 6. Owners(s) of Substance to be Mined (check applicable box(s)): x Private _ State _ Federal _ Indian 7. Owner(s) of Record of Affected Land (check applicable box(s)): x Private _ State _ Federal _ Indian g, Type of Mining Operation (check applicable box (s )): X Surface _ Underground _ In-situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: San Miguel PRINCIPLE MERIDIAN c ec one 6th (Colorado) 10th QNew Mexico) Ute TOWNSHIP (write number and check direction): T a3 x North South RANGE (write number and check direction): R 12 _ East x West SECTION (write number): S 3z QUARTER SECTION (check one): N~- x NW SE SW QUARTER/QUARTER SECTION (check one): _ NE x NW _ SE _ SIJ GENERAL DESCRIPTION: (miles and direction 15 ~~+lus south of Norwood, CO. Elev. 9080 _ from nearest town and approximate elevation) * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.