PERMFILE125976

• Permit No: M1984156
• IBM Index Class Name: Permit File
• Doc Date: 8/24/1984
• Doc Name: LIMITED IMPACT 110 AND SPECIAL TEN DAY 111 PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

Form 5510-I U~ED STATES
(October 198() DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGF,MENT
FREE USE APPLICATION AND PERMIT
VEGETATfVE OR MINERAL MATERIAL
Name of applicant
Kind
Give legal 1.
TOWNSHIP
1 North 79 West 8
• FORM APPROVED
OMB NO. 1004-0001
E spires: 10/31!84
Permit Num6rr
Estimated quantity
_ __ Maximum
SUBDIVISION
Expiration Datc
istnct
Address (snrhrrlr cis r'odr) - - __------ --
ICourthouse
I CERTIFY That 1 am twenty-one years of age or older, a citizen of the United States, and resident of the Stale of
I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best
of my knowledge and belief and are made in good faith.
Zj ~t,16USt I`~84 > ~.
(Date) ( ignature
Title 18 U.S.C. Section 1001, makes it a crime (or any person knowingly and w Ilfu ly to make to any department or agency of the
United Steles any false, (utitiou s, or fraudulent statements or re pros enla(ions o any matter within its junsd icti on.
PERMIT
SPECIAL CONDITIONS
This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was
issued erroneously or the terms or conditions contained herein are not observed. It shall be subject to the following
special conditions:
information is collected to comply with Statutes (16 U.S.C. 604-606) and agency Regulations (43 CFR 5511.1-1(Q).
Information is used to confirm the residence of the applicant.
Applicant must respond to obtain a permit.
Conservation practices must be carried out as provided
by 43 CFR 5511.1-1(b), .2-3(c), and .3-3;
Equipment, personal property, and improvements must
be removed within ninety (90) days after expiration
date (43 CFR 3621.4(c) or 5511.3-5);
Any use of the surface of the lands involved in this
permit shall be such as not to interfere with any mining
claim subject to the provisions of Section 4 of the Act
of July 23, 1955 (30 U.S.C. 613);
(Date)
The permittee shall clean up all work areas and shall
remove or dispose of all refuse resulting from the
perm ittee's operations;
This permit is issued under the pct of July 31, 1947, as
amended, and 43 U.S.C. and 1201, and under the tree use
privilege of the Act of May 14, 1898 (Alaska).
An annual report indicating the amount (cu. yds. or tons)
of material removed must be filed with the Dis-
trict Office on the anniversary date of [he permit, or
within tFrrty (30) days n/tar permit expiration.
(Signature o[ Authorized Officer)
Rnad_Maintenance __ _ _ _ __ _ _ _
I hIEREl3Y AGREE TO COMPLY WITH the special conditions as set forth below. I CERTIFY That the: (a) materials
to be removed are to be used [or the purpose noted above; (b) none of the materials removed are to be sold or bartered;
(c) removal of materials can begin only upon receipt of an approved copy of this permit; and, (d) the authorized officer
is to be notified upon completion of removal.