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i III IIIIIIIIIIIIIIII~ <br />999 <br />LIMITED IMPACT OPERATION (110(2)) <br />,~ , <br />-,, <br />APPLICATION FORM ~ <br />~ ~' <br />~~~~„~ <br />The Application fora Limited Impact Operation Reclamation Permit contains thresfti~m~or <br />parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the i,~.,J, <br />application fee. When you submit your Application, be sure to include two signed copies <br />of the Application Form, tvro copies of Exhibits A-F, and a check for the app rca ion fee <br />described under (4) below. To expedite processing, please provide the information in <br />the format and order described in this form. <br />______________________________________________ ~1_QS?-=1~~ ==._1_ya~7_====________ <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />1. Applicant/Operator Name: Herown En <br />2. Operation Name (Pit, mine or site name): <br />ises <br />MARTIN PIT 1-A <br />3. Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* 9.32 permitted acres. <br />($10 x (affected acres) + E25.00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. $125.00 application fee. <br />5. Substance(s) to be mined (e.g., gold/silver/gravel): SAND & GRAVEL <br />6. Owners (s) of Substance to be Mined <br />(check applicable box (s )): XX Private _ State _ Federal _ Indian <br />7. Owner(s) of Record of Affected Land <br />(check applicable box (s )): X~ Private _ State _ Federal _ Indian <br />8. Type of Mining Operation <br />(check applicable box (s )): XX_ Surface _ Underground _ In-situ <br />9. Location Information. The center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: MOFFAT <br />PRINCIPLE MERIDIA c ec one 6th olorado) 10th (New Mexico) Ute <br />TOWNSHIP (write number and check di n.): T 6 XX North South <br />RANGE (write number and check direction): R 91 _ East ~j West <br />SECTION (write number): S <br />QUARTER SECTION (check one): ~ ~ NW SE SW <br />QUARTER/QUARTER SECTION (check one): _ NE _ NW ~ SE _ SW <br />GENERAL DESCRIPTION: <br />(miles and direction 2i MILES $OUTfi OF ~RAIG~ COLD <br />from nearest town and <br />approximate elevation) 64R(1 AnnvF SFA 1-FVF~ <br />~ ~~ <br />* If the operator is a unit of State or county government, an application fee is not <br />required. A fraction of an acre must be counted as one acre for fee calculation. <br />