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<br />RECEfVED ~~f' ~ <br />OCT 192004,/ <br />Olvlrlon of Minerals end Geology u.l~ <br />CONSTRUCTION MATERIALS CCT 1 ~' ?C04 <br />REGULAR (112) OPERATION / ":risiu <br />RECLAMATION PERMIT APPLICATION FORM ~ ~ 1~&°'L" F' E,; ~rl,~, <br />CHECK ONE: ~ There is a File Number Already Assigned to this Operation <br />Permit # M -L- y - Qq((' (Please reference the file number curtently assigned to this operation) <br />New Application (Rule 1.4.5) T Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.1 l) / <br />Permit # M -~ i ~ -~-~ (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 (I) complete signed and notarized ORIGINAL and one (1) copy of the completed <br />application form, iwo (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 />GENERAL OPERATION INFORMATION <br /> <br />Type of organization (corporation, partnership, etc.): <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 />4. Fees: <br />4.1 New Application <br />4.2 New Quarry Application <br />4.4 Amendment Fee <br />4.5 Conversion to l l2 operation (set by/lstatute) ~ <br />5. Primary commoditie(s) to be mined: l~Y(1l.UJY <br />5.1 Incidental commoditie(s) to be mined: 1. ~ - Ibs/Tons/ r <br />__ <br />~ <br />Q <br />_ _ permitted acres <br />2 <br />' <br />1 <br />`'t 3 acres <br />~ __ acres <br />$2,344.00 application fee <br />$2 906.00 quarry application <br />$1,938.00 amendment fee <br />$2,344.00 conversion fee <br />2. / ]bs/Tons/vr <br />3. / Ibs/Tons/vr 4. / Ibs/Tons/vr 5. / Ibs/Tons/vr <br />5.2 Anticipated end use of primary commoditie(s) to be mined: ,, f 0 <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: I V {~ <br />Type or print clearly, in the space provided, ALL information requested below. <br />