NOTE: DO NOT MODIFY THIS FORM. Submit two (2) copies one of which must be an original.

 

STATE OF WYOMING
DEPARTMENT OF ENVIRONMENTAL QUALITY
LAND QUALITY DIVISION

APPLICATION FOR LICENSE TO EXPLORE FOR MINERALS BY DOZING
NONCOAL - CHAPTER 5 RULES AND REGULATIONS

 

1. Name, mailing address and telephone number of applicant:
Name:      Telephone:
Street:      Fax:
City: State:       Zip
2. Name(s), address(es) and telephone number(s) of the agent or person who will be present and/or responsible for the exploration operation:
Name:       Telephone:
Street:       Fax:
City:     State:       Zip
3. Attach the following information as part of the specific appendices:

(a) APPENDIX "A"
Names and addresses of the owners of record of the surface of all lands to be affected.

(b) APPENDIX "B"
Names and addresses of the owners of record of the mineral rights to all lands to be affected.

(c) APPENDIX "C"
The location(s) of all lands by legal subdivision, section, quarter section (when applicable), township, range and the estimated acreage in each section which will be substantially affected by the applicant.

(d) APPENDIX "D"
A description of the land which shall include: Past and present land uses; vegetative cover; nature and depth of the overburden, topsoil, and mineral seams as nearly as possible.

(e) APPENDIX "E"
An original United States Geological Survey topographic map, clearly outlining and identifying the lands to be explored. An aerial photograph of suitable scale may be substituted for the USGS topographic map provided that items (i) - (vi) below are submitted and all section, township and range lines, identifying numbers, and a north arrow are added.

The following items must be shown on the USGS topographic map or the aerial photo.

(i) Access roads to be constructed.
(ii) Locations of public roads providing access to the area.
(iii) Dwellings and utilities.
(iv) Surface drainage, surface waters and impoundments, and springs.
(v) Earth and debris disposal areas.
(vi) The area of activity shall be shown in more detail and distinctly outlined and identified.

(f) APPENDIX "F"
A description of the proposed exploration activities including: equipment, size of excavation, topsoil salvage and procedures to prevent water pollution. Also, a reclamation plan including procedures for backfilling, topsoil replacement, and seeding.