PERMFILE101184

• Permit No: M1995023
• IBM Index Class Name: Permit File
• Doc Date: 4/4/1995
• Doc Name: LIMITED IMPACT OPERATION 110 RECLAMATION PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

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o .LIMITfiD IMPACT OPERATION (110) • 'II'll'I"I"""~'
RECLAMATION PHRMIT 999
APPLICATION FORM HFn ~ y 13y5
CHHCK ONE: X New Application (Rule 1.4) Conversion Application (Rule 1.11)1,
Permit # M - {provide for conversions of e:E~Ptlid@iAQ( ~9~~~'BOlo9Y
The application for a Limited Impact Designated Mining Operation Reclamation Permit contains
three major parts: (1) the application form; (2) Exhibits A-J, any required sections of
Exhibit S and Geotechnical Stability Exhibit, ae 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) eioned and notarized original and one (1) copy of the
application form, two (2) copies of Exhibits A-J, appropriate sections of 6.4.19 Exhibit S
and 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee
described under (4) below. Exhibits should not be bound or in a 3-ring binder; maps should
be folded to B 1/2" X 11" or 8 1/2" X 14" size. To expedite processing, ease provide the
information in the format and order described in this form. ~ _-Q~_/~'17 ~
______________________________________________________________________ _ __°- 3.~.~
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GENERAL OPERATION INFORMATION
Type or print clearly, in the space provided, all information described below.
3 - + ~- -1 -J 3 - Q S
1. Applicant/operator or company name (name to be used on permit):
^(erlin J, and Shirlev F. teterson
1.1 Type of organization (corporation, partnership, etc.11: individual-
1.2 I.R.S. Tax ID No. or Social Security Number: SZ`-25~T
2. Operation name (pit, mine or site name): Peterson Pit
3. Permitted acreage (new or existing site): ~ 9 9 "~.~ permitted acres
3.1 Change in acreage (+ or -) ~ acres
4. Fees:
4.1 New Application ~ 5875.00 application fee
4.2 Conversion Fee (from 110d to 110 875.00 conversion fee (Rule 1.11.2(2))
5. Primary commoditie(s) to be mined: sand gravel
6. Name of owner to the subsurface rights of affected land: Eta of Col rado
7. Name of owner to the surface of affected land: State o+ Colorado
8. Type of mining operation: X Surface _ Underground ~ In-situ
9. Location information. The ent r of the area where the majority of mining will
occur lies in: JACKSON
COIINTY:
PRINCIPAL MHRIDIAN (check one): _ 6th (Colorado) _ 10th (New Mexico) _ Ute
SHCTTON (write number): S 36_
TOWNSHIP (write number and check direction): T -~ ~ North South
RANGE (write number and check direction): R -~ _ Hast _~ West
QIIARTHR SHCTION (check one}; _ NS _ NW _ SH Y SW
QUARTfiR/QUARTHR SHCTION (check one): _ NS _ NW _ SH ~ SW
GSNHRAL DSSCR ; N: ~~mm lee~n d ddetection from nearest town and approximate
elevation) miles N.~, of Could CO. - 13 miles S.E. of Walden CO
5550' to 8575'
10. Correspondence Information:
APPLICANT/OPHRATOR (name, address, and phone of name to be used on permit)
Contact's Name: Merlin 1 pe ercon Title:
Company Name:
Street: 1671 Jackson Countv Road Lk 30
City: Glal don
State: Cq Zip Code: SO480
Area Code: 303 Telephone: [phone]
0R0~~~lAL