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- - - III IIIIIIIIIIIII III , ~~-~ h: n 4~,, ~dAY 2 4 i~y~ LIMITED IMPACT OPERATION (110(2)) PAINED L1~P)U APPLICATION FORM ._.•: ~MAT,nM n~;,••, The Application for. a Limited Impact Operation Reclamation Permit contains three major parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the application fee. When you submit your Application, be sure to include two si ned copies of the Application Form, two copies of Exhibits A-F, and a check for the app rca ion fee described under (4) below. To expedite processing, plea a provide the information in the format and order described in this form. ~ c/~~_ 7~ GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. 1. Applicant/Operator Name: San Juan County 2. Operation Name (Pit, mine or site name): Fairak a rravPl r;+ 3. Application type: Limited Impact Operation (110). 4. Application Fee for Permitted Acreage* ~,rPA permitted acres. (E10 x (affected acres) + E25.00).* Note permitted acreage and application fee and attach a check for this amount when you file. application fee. 5. Substance(s) to be mined (e.g., gold/silver/gravel): ~,/~,~~ 8r=~,a~,rci~" ~a~-~~~ 6. Owners (s) of Substance to be Mined (check applicable box (s )): ~ Private _ State ~ Federal _ Indian 7. Owner(s) of Record of Affected Land (check applicable box (s )): ~ Private _ State ~ Federal _ Indian 8. Type of Mining Operation (check applicable box (s )): ~ Surface _ Underground _ In-situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: San PRINCIPLE ER A c ec one 6th (Colorado) TOWNSHIP (write number and check direction): T ~~ RANGE (write number and check direction): R ~ SECTION (write number): S 19 QUARTER SECTION (check one): ~~~ QUARTER/QUARTER SECTION (check one): GENERAL DESCRIPTION: 10th (New Mexico) Ute ~ North South East X West _ NW _ SE _ SW NW SE SW (miles and direction 7.8 miles gprtheast of Silverton, Colorado on from nearest town and c y ro d //2 at old Eureka town site elevation approximate elevation) $$~~ fee. * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.