PERMFILE59998

• Permit No: M1995010
• IBM Index Class Name: Permit File
• Doc Date: 2/6/1995
• Doc Name: LIMITED IMPACT OPERATION 110 RECLAMATION PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

ll'lllll'IIIII'~II • LIMI~RHCLAMATIONH BTRMIT (110)• RECEIVED
APPLICATION FORM FEB ~j
CHHCK ONH: X New Application (Rule 1.4) Conversion ApplliYCation (Route X951)
Permit # M - (provide for conversions ~Z~~x7i0) its)
a~~eolo9Y.
The application for a Limited Impact Designated Mining Operation Reclamation Permit contains
three major parts: (1) the application form; (2) Hxhibits A-J, any required sections of
Hxhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in
Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; and (3) the application fee. When you submit your
application, be sure to include one (1). sicmed and notarized original and one (1) copy of the
application form, two (2) copies of Hxhibite A-J, appropriate sections of 6.4.19 Hxhibit S
and 6.5 (Geotechnical Stability Hxhibit), ae required, and a check for the application fee
described under (4) below. Hxhibite should not be bound or in a 3-ring binder; maps should
be folded to 8 1/2" X 11^ or 8 1/2" X 14" size. To expedite procesei~q, please provid tYye
information in the format and order described in this form. 1~ 1~ =QL~__C
GHNBRAL OPHRATION INFORMATION ~ 77j
Type or print clearly, in the space provided, all information described below.
--------- -------------
l. Applicant/operator or company name (name to be used on permit):
1.1 Type of organization (corporation, partnership, etc.): County Government
1.2 I.R.S. Tax ID No. Or Social Security Number:
2. Operation name (pit, mine or Bite name): Black Snag
3. Permitted acreage (new or existing site): 9.9 permitted acres
3.1 Change in acreage (+ or -) acres
4. Pees:
4.1 New Application ~ 5875.00 application fee
4.2 Conversion Fee (from 110d to 110 875.00 conversiaa fee (Rule 1.11.2(2))
5. Primary commoditie(s) to be mined: Gravel
6. Name of owner to the subsurface rights of affected land: BLNI
7. Name of owner to the surface of affected land: RTM
8. Type of mining Operation: X Surface _ IInderground _ In-situ
9. Location information. The center of the area where the majority of mining will
occur lies in:
COONT'Y: _ _S
PRINCIPAL MHRIDIAN (check one): _ 6th (Colorado) 10th (New Mexico) _ IIte
SHCTION (write number): S _
TOWNSHIP (write number and check direction): T 42 North South
RANGH (write number and check direction): R I _ Haet ~ West
QQARTHR SHCTZON (check one): _ NH _ NW _ SH _ SW
QLARTHR/QW,RTHR SHCTION (check one): _ NH _ NW _ SH _ SW
GHNHRAL DHSCRIPTION: (miles and direction from nearest town and approximate
elevation)
10. Correspondence Information:
APPLICANT/OPHRATOR (name, address, and phone of name to be used on permit)
Contact's Name: Le~Y Gore Title• County Coirtni.ssioner
Company Name: Dolores County
Street: P.O. Hox 608
City: Dove Creek
State: Colorado zip Code: 81324
Area Code: 303 Telephone: [phone]
~~NF1G
ORIGINAL of