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7/78 • <br />LIMITED IMPACT (110) and <br />SPECIAL TEN-DAY (111) PERMIT <br />APPLICATION FORM <br />State of Colorado R EC E 1V E D <br />Department of Natural Resources <br />MINED LAND RECLAMATION BOARD ~ Ci n ~ Is7~ <br />1313 Sherman Street, Room 723 ~~ <br />Denver, CO 80203 (303) 839-3567 <br />• III IIIIIIIIIIIIIIII <br />n <br />~~~~~5 `~ <br />Application for Mining and <br />Reclamation Permit, pursuant <br />to CRS 1973, 34-32-101, et seq <br />RECL^,i:~~,1ICiV SECTION <br />CoiD. Dept. of tfaturzl ResDOrces <br />The following explanations cover Limited Impact applications (IIOs) and Special (Ten- <br />Day Processing)(llls) applications. In the interests of efficient processing, please <br />check the appropriate box to indicate which type of application you are applying for here. <br />'~~ LIMITED IMPACT OPERATIONS must disturb LESS THAN ten acres (including <br />all roads, stockpile areas and any other surface facilities) over the <br />life of the mine, and must extract LESS THAN 70,000 tons of mineral, <br />overburden or combination thereof per calendar year. If the affected <br />area is some fraction greater than nine acres, be sure NOT to round this <br />figure out to ten acres in the narratives or elsewhere. <br />SPECIAL (TEN-DAY PROCESSING) operations must disturb LESS THAN ten acres <br />(including all roads, stockpile areas and any other surface facilities), <br />and can ONLY be obtained where a federal, state, county, city, town or <br />special district contract calls far work to be commenced within a <br />GD[f i[Il'GI I V ful1DT TIY[ _ <br />F <br />(Type or Print Clearly) <br />~'- 3 3 ~ <br />I. Name of operation <br />~ ~ d ' <br />~ <br />~ ~ <br /> (Pit, mine or site name) i <br />2. Name of applicant/operator ~ , ~n ~ ~ 7 <br /> (Name to be used on permit) <br />3. Address and phone number of [~j <br /> local offices <br />~o D <br />~ <br />8 -8 yi3 <br />4. Address and phone number of <br /> general offices <br />S. Name and phone number of person _ ~ _ ~ ~ ? <br /> staff members should contact <br />6. Owner(s) of record of affected <br />land (surface area) (If more _ <br />t T _ / <br />T/ode J.,O <br /> than 2, list below) w A Q R rN n v~ 8 <br />~" <br />7. Owner(s) of substance to be mined <br /> (If more than 2, list below) <br />8. Source of legal right to enter <br />(Indicate what type of proof is ~ ~ <br />„ -1 - _ <br />( f / / <br /> included in EXHIBIT G - lease, <br />deed, notarized letter, etc.) <br />9. Type of mine E substance to be <br />mined (Specify underground, strip, <br />L NG' b.S _ <br />~ <br /> open pit, etc. b substance(s) to <br />be mined) <br />_ <br />10. General location E elevation <br />(Miles !; direction from nearest <br />L' ,~/~ <br />!V V/. <br /> town b approximate site eleva- <br />tion) <br />I1. County <br />12. Acreage of affected lands <br />(Total surface acreage to be <br />included in ermit <br />/ p <br />L C/i ~ <br />13• Application fee (See applicable <br />RULE to determine amount) <br />7 ~"' ~ <br />Orh~y <br />"T' <br /> <br />~y <br />i <br />(over) <br />