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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX: (303) 832 -8106 <br />CHECK ONE: <br />1. <br />CONSTRUCTION MATERIALS <br />LIMITED IMPACT (110) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM <br />5. Primary commoditie(s) to be mined: Gravel Sand <br />STATE OF COLORADO <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information described below. <br />6.74 <br />5.1 Incidental commoditie(s) to be mined: 1. / lbs/Tons/yr 2. / lbs/Tons/yr 3. <br />4. / lbs/Tons/yr 5. / lbs/Tons✓vr <br />5.2 Anticipated end use of primary commoditie(s) to be mined: Local roads and const. 'obs <br />Anticipated end use of incidental commoditie(s) to be mined: <br />Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango <br />COLORADO <br />DIVISION OF <br />RECLAMATION <br />MINING <br />— &— <br />SAFETY <br />Bill Ritter, Jr. <br />Governor <br />Harris D. Sherman <br />Executive Director <br />Ronald W. Cattany <br />Division Director <br />Natural Resource Trustee <br />There is a File Number Already Assigned to this Operation <br />_ <br />permit M - 2011 _ 027 (Please reference the ber currently assigned to this operation ) <br />New Application (Rule 1.4.5) U Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.11) <br />Permit # M - 2011 - 027 - (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Limited Impact (110) Operation Reclamation Permit contains three major parts: (1) the <br />application form; (2) Exhibits A J, Exhibit L, Addendum 1, any sections of Exhibit 6.5 and Geotechnical Stability Exhibit, as required <br />by the Office, and outlined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); and (3) the application fee. When you submit your application, be <br />sure to include one (1) complete signed and notarized ORIGINAL and one (1) copy of the completed application form, two (2) copies <br />of Exhibits A -J, Exhibit L, Addendum 1, and appropriate sections of 6.5 ( Geotechnical Stability Exhibit), as required, and a check for <br />the application fee described under (4) below. Exhibits should NOT be bound or in a 3 -ring binder; maps should be folded to 8 1/2" X <br />11" or 8 1/2" X 14" size. To expedite processing, please provide the information in the format and order described in this form. <br />Applicant/operator or company name (name to be used on permit): k1-i N Ago L. WA M 5 Ley <br />1.1 Type of organization (corporation, partnership, etc.): Sole Proprioter <br />2. Operation name (pit, mine or site name): Wamsley Pit <br />3. Permitted acreage (new or existing site): 6.74 <br />3.1 Change in acreage ( +) <br />3.2 Total Acreage in Permit Area <br />4. Fees: <br />4.1 New Application: <br />Amendment Fee (C.R.S. 34- 32:5 - 125(11)): <br />4.2 Conversion Fee (from 110d to 110 $2,696.00 conversion fee (Rule 1.11.2(2)) <br />permitted acres <br />acres <br />acres <br />$1,258.00 application fee <br />$827.00 application fee <br />/ lbs/Tons/vr <br />Office of <br />Active and Inactive Mines <br />