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J <br />~ <br />~ <br />III II IIIIIIIIIIIII <br />MITED IMPACT AND SPECIAL I;TE <br />AY) ~ <br />PERMIT APPLICATICt1 FORM sss <br />STATE OF COLORADO Appll ation for Pfining <br />t~itaed Laad Reclamation Board and clamation Perait, <br />Depar*_ment of Natural Resources Pursu nt to C.R.S. 1973, <br />1313 Sherman Street, Room 723 34-32 101, et seq. <br />Denver, Colorado 80203 <br />~( LII•fITED I,'3PACT OPERATIONS must disturb LESS THAN ten acre (including all <br />roads, stockpile areas and any other surface facilities) <br />R ver the life of <br />the mine, and must extract LESS THA:d 70,000 tons of miner <br />~ 1, overburden <br />~~ <br />combination thereof per calendar year. If the affecte area is some <br />O on greater than nine acres, be sure NOT to round it <br />narratives or elsewhere. <br />~' up to ten acres <br />C <br />1 8~4ECIAL (TEN-DAY PROCESSING) o <br />erations must disturb LESS THAN ten <br />p <br />(i <br />l <br />di <br />d <br />'•~ <br />ll <br />d <br />k <br />il <br />h f <br />nc <br />u <br />ng a <br />s, stoc <br />e areas an <br />er <br />~ <br />/~ acres <br />roa <br />p <br />any ot <br />~ sur <br />ace <br />ag~~,facilities), anr~ can ONLY be obtained where a federal, st te, county, <br />~l~--~11dd.. town, or special district contract calls for work t <br />~mmifnced within a SPECIFICALLY SHORT TIME. be <br />~, <br />TYPE OR PRINT CLEARLY /rI $ 5 Z 12 (o <br />1. Name of operations .~ r ~ <br />(Pit, mine, or site name) I , <br /> M <br />/4 ~S <br />°Cf <br />2. Name of applicant/operatcr r ~ /~ <br />^ <br />(Name to be used on permit) <br /> S o <br /> I <br />3. Address and phone number of F <br />local offices <br />D <br /> V 0 <br />k. Address and phcne number M <br />of general offices <br />5. Name and phone number of person ~ 7 ~ l°1 G ~0 <br />staff members should contact ~ O <br />6. Owner(s) of record of affected i ~ ~ h Yr0 <br />land (surface area) <br /> <br />(If more than 2, list below) <br />7. Owner(s) of substance to be mined p y, <br />(If more than 2, list below) <br />8. Source of legal right to enter .pip ~p ~ <br />(Indicate what type of proof is <br />included in 2xhibit G - lease, deed, Q g <br />notarized letter, etc.) <br />9. Type of mine fi substance to be mined <br /> <br />(Specify underground, strip, open pit, <br />etc. and substance(s) to be mined} ~ <br />General location F elevation (Miles I <br />0 ~ y ~ r <br />. <br />b direction from neazest town 6 ~ <br /> <br />l _ <br />C <br />evation) <br />approximate site e <br /> S ~ <br />1. county I YV P N <br />2. Acreage of affected lands ~ -~' ' t = <br /> ' " - <br />(Total surface acreage to be <br /> ~ _ <br />included in permit) <br />13. Application fee (See applicable Rule I ~QJ_ 1 ~~ <br />to determine amount) <br />~~ :;~,e.', Fc~t~ Caen ~ o.~ P he ~ < <>c e, F~ ~ ~ ~ ,. <. <br />J <br /> <br /> <br /> <br />r <br />