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1 <br /> <br />rdgY p ~ ;9.y. <br />LIMITED IMPACT OPERATION (110(2)) MINED ~gPJD <br />APPLICATION FORM a~=CL~MAT!QA~ p11nc• -, <br />The Application fora Limited Impact Operation Reclamation Permit contains tfiree major ~ <br />parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the <br />application fee. When you sudnit your Application, be sure to include two si ned copies <br />of the Application Form, two copies of Exhibits A-F, and a check for the app ca ion fee <br />described under (4) below. To expedite processing, please provide the information in <br />the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, 1n the space provided, all information described below. <br />---- ------------- <br />~~~° ~ ~~® <br />1. Applicant/Operator Name: [ii/I¢S~t iN47etJ (~u.N ~ y <br />2. Operation Name (Pit, mine or site name): Ch A~s l~~ eSoN GR/4Ur/ P~T <br />3. Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* ~J, yg permitted acres. <br />(Si0 x (affected acres) + $25.00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. l,/oNt application fee. <br />5. Substance(s) to be mined (e.g., gold/silver/gravel): ~r R /} V e <br />6. Owners(s) of Substance to be Mined <br />(check applicable box(s)): ~ Private _ State _ Federal _ Indian <br />7. Owner(s) of Record of Affected Land <br />(check applicable box(s)): ~ Private _ State _ Federal ,Indian <br />8. Type of Mining Operation <br />(check applicable box(s)): ~/ Surface _ Underground _ In-situ <br />9. Location Information. The center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: (~[ d S h: N~f /O1~ <br />~ <br />PRINCIPLE FiER ec one <br />Vth (Col orado) 10th (New Mexi co) Ute <br />TOWNSHIP (write number and check direction): T ~ North South <br />RANGE (write number and check direction): _ <br />R u~~ East YWest <br />SECTION (write number): S -S _ <br />QUARTER SECTION (check one): ~ NW j/$E SW <br />QUARTER/QUARTER SECTION (check one): NE j~NW _ SE = SW <br />GENERAL DESCRIPTION: , <br />(miles and direction lS M;/es uaRTh d- °1 M~leS EAST o~ O j;s, (otrA~~• <br />from nearest town and <br />approximate elevation) a, 3v0 ~~ GT <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 />