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III IIIIIIIIIIIII III • ~r~^,~ivF..f~ APR 13 1995 LIMITED IMPACT OPERATION (110) RECLAMATION PERMIT APPLICATION FORM Division of ~wnerais t~ Geo ogy CHECK ONE: X New Application (Rule 1.9) Conversion Application (Rule 1.11) Permit # M (provide for conversions of existing permits) The application fora Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (1) the application form; (2) Exhibits A-J, any required sections of Exhibit S and Geotechnical Stability Hxhibit, as required by the Office, and outlined in Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; and (3) the application fee. When you submit your application, be sure to include one (1) sinned and notarized original and one (1) copy of the application form, two (2) copies of Hxhibite A-J, appropriate sections of 6.4.19 Exhibit S and 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described under (4) below. Exhibits should not be bound or in a 3-ring binder; maps should be folded to 8 1/2" X 11" or 8 1/2• X 14• size. To expedite processi please provide the information in the format and order described in this form. ~- .(]Z ---------------------- - GSNSRAL OPERATION INFORMATION Type or print clearly, is the space provided, all information described below. 1. Applicant/operator or company name (name to be used on permit): Rick Peters/Park County Road & Bridge/Ansley Pit ~2_ _ __ ______ 1.1 Type of organization (corporation, partsiership, etc.): Government 1.2 I.R.S. Tax ID No. or Social Security Number: 2. Operation name (pit, mine or site name): Ansley Pit #2 3. Permitted acreage (new or existing site): 9.9 permitted acres 3.1 Change in acreage (+ or -) acres 4. Fees: 4.1 New Application 5875.00 application fee 4.2 Conversion Fee (from S10d to 110 875 00 conversion fee (Rule 1.11.2(2)) 5. Primary commoditie(s) to be mined: pit run y. 6. Name of owner to the subsurface rights of affected land: park County 7. Name of owner to the surface of affected land: park County e. Type of mining operation: ~ Surface _ Oadergrauad _ Za-situ 9. Location information. ,The center of the area where the majority of mining will occur lies in: p~.k COi)NTY: PRINCIPAL MERIDIAN (check one): ~, 6th (Colorado) ~ 10th (New Mexico) _ Dte SECTION (write number): S TOWNSHIP (write number and check direction): T 10 _ North }~ South RANGB~(write number and check direction): R "77 _ Sast - ~ West QLD\RTSR SHCTION (check one) : ~ _ NS _ NW _. SS ~(. SH QDARTHR/QII;iRTER SECTION (check one): _ ^ SH GENERAL DHSCRSPTION: (miles and direction from nearest town and approximate ~ elevation) =ThrPa milPS snnfh asst of Fai mlav Colnratlo nn Highway 9 10. Correspondence information: APPLICANT/OPERATOR (name, address, and phone of name to be used on permit) Contact's Name: Rick Peters Title: NCSi stint COOrnin3tor Company Name: Park County Road and Bridge Street: 1246 County Road 16 City: Fairplay State: C~ Zip Code: 80440 Area Code: 714 Telephone: R"tF,-771 Fxr 777 ORIGINA(~