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IMITED IMPACT OPERATION (110(2)1 QCT 2 7 1~9,j RECLAMATION PERMIT APPLICATION FORM ~•~,c~ , The application fora Limited Impact Operation Reclamation Permit contains three major parts: (1) the application form; (2) Exhibits A-J; and, (3) the application fee. When you submit your application, be sure to include two (2I signed originals of the application form, two (2) copies of Exhibits A-J, and a c~c~for the application fee described under (3) below. To expedite processing, please provide the information in the format and order described in this form. _____________________________________________________~!_=~3==~~__====_-_- _a~~~~--- GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. ----------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- 1. Applicant/operator name: Logan County Board of Commissioners 1.1 Type of organization (corporation, partnership. etc.): County Government 2. Operation name (pit, mine or site name): Lindstrom Gravel Pit 2.1 I.R.S. Tax ID No. or Social Security No. 3. Application fee for permitted ac reage* Note permitted acreage and application fee and attach a check for this amount when you file. 4. Substance(s) to be mined (e. g., gravelJgold/borrow): 9.98 permitted acres $875 application fee Sand b Gravel 5. Name of owner of surface of affected land: Neil rt. Lindstrom 6. Name of owner of subsurface rights of affected land: same 7. Type of mining operation: g Surface Underground In-situ 8. Locat ion information. The center of the area where the majority of mining will occur lies in: COUNTY: Logan PRINCIPAL MERIDIAN (check one): x 6th (Colorado) 10th (New Mexico) Ute TOWNSHIP (write number and check direction): T 6 x North South RANGE (write number and check direction): R 51 East ~ West SECTION (write number): 5 17 QUARTER SECTION (check anel: -AE x NW SE SW QUARTER/QUARTER SECTION (check one): x NE _ NW SE ~ SW GENERAL DESCRIPTION: (miles and direction _Eleven miles southeast of Sterling from nearest town and approximate elevation) ,,.,.,_,..,,m,r o,., i,~nn fr * A fraction of an acre must be counted as one acre for fee calculation. If the operator is a unit of state or county government, an application fee is not required.