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iii iiiiuiiiiiu iii ; ~ ~~ ,~ ,~ , <br />(~ (~ I. 4 <br />GCfi 3 01~6~ <br />MINED LANp <br />LIMITED IMPACT OPERATION (110(2)) RECLAMATION DIVIStO~y <br />APPLICATION FORM <br />The Application for a Limited Impact Operation Reclamation Permit contains three major <br />parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the <br />application fee. When you submit your Application, be sure to include two signed copies <br />of the Application Form, two copies of Exhibits A-F, and a check for the app Ica Ion fee <br />described under (4) below, To expedite processing, please provide the information in <br />the format and order described in this form. n~.~;q_~~ z <br />----------------------------------------------------------------------------------------- <br />----------------------------------------------------------------------------------------- <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />---- ------------------------------- <br />1. Applicant/Operator Name: MOFFAT COUNTY ROAD DEPARTMENT <br />2. Operation Name (Pit, mine or site name): <br />REFUGE FIT N0. 1 <br />3. Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* 9,$1 permitted acres. <br />(E10 x (affected acres) + 325,00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. (CouNTY)$0.00 application fee. <br />5. Substance(s) to be mined (e.g., gold/silver/gravel): ROADBASE~ GRAVEL 8 SAND <br />6. Owners (s) of Substance to be Mined <br />(check applicable box(s)): _ Private _ State X~(Federal _ Indian <br />7, Owner(s) of Record of Affected Land <br />(check applicable box(s)): _ Private _ State XXX 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 ERIDIA c ec one 6th (Colorado) 10th (New Mexico) Ute <br />TOWNSHIP (write number and check direction): T 10 XX North South <br />RANGE (write number and check direction): R IUr- East ~CXWest <br />SECTION (write number): S <br />~ _ <br />QUARTER SECTION (check one): NW SE yg SW <br />QUARTER/QUARTER SECTION (check one): _ NE _ NW _ SE ~ SW <br />GENERAL DESCRIPTION: <br />(miles and direction 47 MII FS WEST nF MAYRFI I ~ ('I) <br />from nearest town and <br />approximate elevation) ELEVATION: 5540 <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 />