Free 50617.pdf - Indiana

APPLICATION FOR AN INCIDENTAL BOUNDARY REVISION TO A PREVIOUSLY APPROVED PERMIT
State Form 50617 (R / 6-06)

Indiana Department of Natural Resources Division of Reclamation

INDEX
Section - Title Section A - General Information Section B - Right of Entry Information Section C - Relationship to Areas Unsuitable for Mining Section D - Land Use Information and Plans Section E - Bond Information Signature Page Page # 1 2 3 3 4 5

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION

PERMIT NO.

APPLICATION FOR AN INCIDENTAL BOUNDARY REVISION TO A PREVIOUSLY APPROVED PERMIT
A. General Information 1. 2. Applicant's Name Give name, title and address of individual to whom correspondence regarding this application is to be sent: Telephone Name Title Address Number

3. 4. 5. 6a. 6b. 6c. 6d. 6e.

Pit Name County U.S.G.S. Quadrangles Acres to be added by this application: Shall not exceed limits set forth in 310 IAC 12-3-121 (c)(1)(v) Coal Removal acres contained within this application: Total previously approved Incidental Boundary Revisions acreage for coal removal: Present Permit acreage not including previous Incidental Boundary Revision acreage: Acres added by previous Incidental Boundary Revisions: #1 #5 #2 #6 #3 #7 #4 #8

7.

Legal Description of the acreage in this application by 1/4, 1/4 Section(s), Township(s), and Range(s):

Application, Page 1

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION

PERMIT NO.

8.

Submit as an attachment a map showing the present permit area and the area proposed under this application. Map

9.

Describe below how the additional acreage is required for the orderly and continuous mining and reclamation operation and indicate the types of activities which are proposed to be conducted on the additional area: Attachment Map

10a.

Describe below how the activities proposed to be conducted on this area do not constitute a significant departure from the method of conduct of mining or reclamation operations contemplated by the original permit.

10b.

Are the activities proposed under this application in conformance with plans which have NO already been approved? YES If YES, describe the proposed plans in relation to approved plans and refer to the applicable section of the approved permit application. Attachment(s) If NO, submit as attachments necessary plans for each activity as required by 310 IAC 12-5-6 through 12-5-158. Attachment(s).

B.

Right of Entry Information 1. List names and addresses of legal or equitable owners of record of all the surface properties, and coal properties to be mined within the permit area: Surface Coal

Application, Page 2

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION Map 2.

PERMIT NO.

Describe below the documents upon which the applicant bases his/her/its legal right to enter and begin the surface coal mining and reclamation operations on the proposed area and indicate whether that right is the subject of pending litigation. The description should identify the specific right claimed by the applicant and identify each document by type and date of execution.

C.

Relationship of Areas Unsuitable for Mining Does any acreage within this application contain any areas designated as unsuitable for mining operations as per 310 IAC 12-2-1 & 12-2-3? YES NO If so, discuss the impact of mining and submit necessary information.

D.

Land Use Information and Plans 1. Pre-Mining uses for the revised area: Cropland Water Other acres acres acres Pasture Land Residential Explain Other below: acres acres Forest Wildlife acres acres

Show the location of pre-mining uses on a map or aerial photograph. Map 2. Proposed post-mining land uses for the revised area: Cropland Water Other acres acres acres Pasture Land Residential Explain Other below: acres acres Forest Wildlife acres acres

Show the location of pre-mining uses on a map or aerial photograph.

Application, Page 3

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION Map

PERMIT NO.

3.

Submit as an attachment, comments from the legal or equitable owner(s) of record of the surface of the proposed permit area, and the state and local government agencies which would have to initiate, implement, approve, or authorize the proposed use(s) of the land following reclamation. Attachment(s)

For any surface owner, are changes from the pre-mining land use acres proposed? YES If YES, then submit the following: a. A description of how the land uses are compatible with adjacent land uses and where applicable with existing local land use policies and plans. Attachment(s) b. A description of the measures to prevent or mitigate adverse effects on fish, wildlife and related environmental values and threatened or endangered plants. Attachment(s) NO

E.

Bond Information 1. Indicate the approved bond rate for the permit area contiguous to the proposed area. If the proposed area is contiguous to areas with more than one bond rate, use the highest rate for those areas. $ 2. per acre

Multiply the acres contained within this application by the rate indicated above. Acre x $ per acre = $ (Total Bond for this Area)

3.

Submit as an attachment a revised bond segment map, which shows how this will be bonded. Map

Application, Page 4

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION
SIGNATURE PAGE

PERMIT NO.

I, (typed or printed name of responsible official or Applicant's legal representative), hereby affirms that all statements and representations made in this application and attachments thereto are true and correct to the best of my information and belief and that I am duly authorized to sign this application on behalf of . (Name of Permittee) I hereby affirm that unless otherwise specifically stated in this application, all activities conducted on any areas described in this application will be mined and reclaimed in conformity with the plans contained in the already approved permit. I hereby affirm that all reclamation fees due as required by 30 CFR 870.12 have been paid to the U.S. Dept. of Interior, Office of Surface Mining. Further, the Director or his authorized representatives, without advance notice or a search warrant, upon presentation of appropriate credentials, and without relay, is authorized to enter upon the through this surface coal mining and reclamation operations. Private persons, for the purpose of conducting an inspection when the inspection is in response to an alleged violation reported to the Director by the private person, may also accompany the Director or his authorized representatives. Signed: Title: (Attach a copy of Power of Attorney or Resolution of Board of Directors, which grants signature authority.)

Subscribed and sworn to before me this My commission expires:

day of

, 20

.

Notary of Public Signature:

Name typed or printed: Residence:

County: State:

Application, Page 5