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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman SL, Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX (303) 832 -8106 <br />P <br />CONSTRUCTION MATERIALS <br />REGULAR (112) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM <br />CHECK ONE: PI There is a File Number Already Assigned to this Operation <br />M - 1.978 078 -Sg (Please reference the file number currently assigned to this operation) <br />New Application (Rule 1.4.5) E Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.11) <br />Permit # M - 978 - 078 _ SG (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Regular 112 Operation Reclamation Permit contains three major parts: (1) the application <br />form; (2) Exhibits A -S, Addendum 1, any sections of Exhibit 6.5 (Geotechnical Stability Exhibit; and (3) the application fee. When you <br />submit your application, be sure to include one (1) complete signed and notarized ORIGINAL and one (1) copy of the completed <br />application form, two (2) copies of Exhibits A -S, Addendum 1, appropriate sections of 6.5 (Geotechnical Stability Exhibit, and a check for <br />the application fee described under Section (4) below. Exhibits should NOT be bound or in a 3 -ring binder maps should be folded to <br />8 1/2" X 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 />2. Operation name (pit, mine or site name): <br />3. Permitted acreage (new or existing site): <br />3.1 Change in acreage ( +) <br />3.2 Total acreage in Permit area <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information requested below. <br />1. Applicant/operator or company name (name to be used on permit): <br />1.1 Type of organization (corporation, partnership, etc.): Local Government <br />4. Fees: <br />4.1 New Application <br />42 New Quarry Application <br />4.4 Amendment Fee <br />4.5 Conversion to 112 operation (set by statute) <br />5. Primary commoditie(s) to be mined: Sand <br />5.1 Incidental commoditie(s) to be mined: 1. <br />George Ansley Pit <br />NONE <br />Gravel <br />3. / lbs/Tons/yr 4. / <br />5.2 Anticipated end use of primary commoditie(s) to be mined: <br />53 Anticipated end use of incidental commoditie(s) to be mined: <br />Office of <br />Mined Land Recamation Denver • Grand Junction • Durango <br />STATE OF COLORADO <br />Lincoln County <br />lbs/Tons/yr 2. / <br />lbs/Tons/yr 5. / <br />County Road Maintenance <br />Not Applicable <br />COLO RADO <br />D I V I S I O N O F <br />RECLAMATION <br />MINING <br />—&— <br />SAFETY <br />9.39 permitted acres <br />7.71 acres <br />17.1 ac res <br />$2,344.00 application fee <br />$2,906.00 quarry application <br />$1,938.00 amendment fee <br />52344.00 conversion fee <br />lbs/Tons/yr <br />lbs/Tons/yr <br />Office of <br />Active and Inactive Mines <br />