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<br />III IIIIIIIIIIIII III RI ECEIV1En~C ~1 <br />LIMITED IMPACT OPEHA'rlun (110) JA ~~~FJ~J/ 1~~ <br />RECLAMATION PERMIT l <br />APPLICATION FORM Divisirn~ of Minerals 8 Geology <br />CI1ECt: ONE: ~ New Application (Rule 1.4) ~ Conversion Application (Rule 1.11) <br />Pz nnit H M ~ - ~~ (provide for conversions of. existing permits) <br />The application for a Limited Impact Designated Mining Operation Reclamation Pei-niC contain; <br />three ma3 or parts: (1) the application form; (2) Exhibits T,-J, any required sections of <br />Exhibit S and Geotechnical Stability Exhibit, ac required by the Office, and outlined ir. <br />Rules G.1, G.2, 6.3, E.4.19 and 6.5; and (3) the application fee. When you submit }•our <br />application, be cure to include one (1) sinned and notarised original and one (1) copy of the <br />application form, two (^_) copies of Exhibits A-J, appropriate sections of G.4.19 Exhibit S <br />and G.5 (Geotechnical Stability D•xhibit), as required, and a check for the application fee <br />de rcri bed under (9) below. F.xhibite should not be bound or in a 3-ring birds r; maps should <br />be folded to B 1/2" X 11" or B 1/2" Y. 14" size. To expedite processing, please provide ehc <br />inEonnation in the Co neat and order described in this form. (Yl - 95._~_ <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />---------------------------- <br />1. F,pplicant/operator name Joe H, Thomeczek - Bent County Read}' Mix <br />1.1 Type of organization (corporation, partnership, etc.): Partnership <br />1.2 I.P.. S. Tax ID No.: <br />?. Operation name (pit, mine or site nani~): Thomeczek Pit <br />3. Permitted acreage (new or existing site): 5'48 permitted acres <br />3.1 Change in acreage (+ or -) + ~.3 acres <br />4. fees: <br />9.1 New Application S©75.00 app]ication fee <br />4.2 Conversion Fee (from 110d to 110 $875.00 conversion Lee (Rule 1.11.2(2)) <br />~. Primary convnoditie(s) to be mined: Sand Gravel <br />G. Name of owner to the surface of affected land: New .43 acres, Harold & Betty KorCz <br />7. Name of owner to the subsurface rights of affected land: New .43 acres Harold & Betty <br />8. Type of mining operation: ~7' Surface _ Underground _ In-situ <br />9. Location information. The center of the aria where the maj orit}• of mining will <br />occur lies in: Bent <br />COUNTY: <br />PRINCIPAL MERIDIAN (check one): X 6th (Colorado) _ 10th (Ne•.~ Mexico) _ Ute <br />SECTION (write number): S _$_ <br />TOWNSHIP (write number and check direction): T Z _ North k Seuth <br />fiAt7GE (write number and check direction): R 52 _ East _ west <br />QUARTER SECTION (checY, one): _ NE _ NW ~ SE _ S'd <br />QUARTER/QUARTER SECTION (check one): _ N6 _ NW ~ SS _ SSa <br /> CR7IPTION: (miles and direction from nearest toom and approximate <br />elevation) 1 z miles west of Las Animas, Colorado Pl avat-inn "191(1 faa+r <br />10. Correspondence Information: <br />APPLICAN'C/OPERATOR (name, address and phone of name to be used on permit) <br />Individual's Name: Joe H. "Ihomeczek Title: Owner <br />Social Security No.: <br />~ Company Name: Bent County Retldy Mix <br />~ 8th & Garfield <br />Street: <br />