Form DMM-101 "Permit/License Application" - Virginia

What Is Form DMM-101?

This is a legal form that was released by the Virginia Department of Mines, Minerals and Energy - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Virginia Department of Mines, Minerals and Energy;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DMM-101 by clicking the link below or browse more documents and templates provided by the Virginia Department of Mines, Minerals and Energy.

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Download Form DMM-101 "Permit/License Application" - Virginia

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DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE 400
CHARLOTTESVILLE, VA 22903
(434) 951-6310
PERMIT/LICENSE APPLICATION
FOR OFFICE USE ONLY
APPLICATION TRACKING #
PERMIT NO.
RECEIPT NO.
DATE ISSUED:
OWNERSHIP INFORMATION
1. Name of Applicant
2. Office Telephone Number
3. Mailing Address
Mine is located
of
(miles)
(direction)
(town)
on Public Road No.
in
County/City
4. Type of Organization:
(
)Sole Proprietorship
- Complete questions A,B,C,D,E,F,G,I
(
)Corporation
- Complete questions A,B,C,D,E,F,G,J,K,L,M,N
(
)Partnership
- Complete questions A,B,C,D,E,F,G,H,I
(
)Other
- Complete questions A,B,C,D,E,F,G,H,J
Specify:
(A)
Name, address and telephone number of the Mine
(B)
MSHA ID number of the Mine (if applicable)
(C)
Person with overall responsibility for operating decisions at the mine:
Name/Title
Address
Phone
(D) Person to be contacted in the event of an accident or emergency:
Name
Address
Telephone
(E) Person with overall responsibility for health and safety at the mine:
Name
Address
Telephone
(F) Person responsible for business operation of the mine:
Name
Address
Telephone
(G) Federal Tax ID Number of Applicant
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DMM-101
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DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE 400
CHARLOTTESVILLE, VA 22903
(434) 951-6310
PERMIT/LICENSE APPLICATION
FOR OFFICE USE ONLY
APPLICATION TRACKING #
PERMIT NO.
RECEIPT NO.
DATE ISSUED:
OWNERSHIP INFORMATION
1. Name of Applicant
2. Office Telephone Number
3. Mailing Address
Mine is located
of
(miles)
(direction)
(town)
on Public Road No.
in
County/City
4. Type of Organization:
(
)Sole Proprietorship
- Complete questions A,B,C,D,E,F,G,I
(
)Corporation
- Complete questions A,B,C,D,E,F,G,J,K,L,M,N
(
)Partnership
- Complete questions A,B,C,D,E,F,G,H,I
(
)Other
- Complete questions A,B,C,D,E,F,G,H,J
Specify:
(A)
Name, address and telephone number of the Mine
(B)
MSHA ID number of the Mine (if applicable)
(C)
Person with overall responsibility for operating decisions at the mine:
Name/Title
Address
Phone
(D) Person to be contacted in the event of an accident or emergency:
Name
Address
Telephone
(E) Person with overall responsibility for health and safety at the mine:
Name
Address
Telephone
(F) Person responsible for business operation of the mine:
Name
Address
Telephone
(G) Federal Tax ID Number of Applicant
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DMM-101
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(H) List all individuals having any ownership interest in the organization.
Name/Title
Address
Telephone
(I) Trade name, address and telephone number for sole proprietors/partnerships:
(J) Principal organization officials, corporate officers, directors and members:
Name/Title
Address
Telephone
(K) Corporation name, address and telephone number if different than applicant:
(L) State of Incorporation
(M) Registered Agent:
Name
Address
Telephone
(N) If a subsidiary, provide:
Parent Organization Name:
Address
Telephone
State of Incorporation
5.
Name, address and telephone number of person(s) authorized to sign permit/license documents:
Name
Address
Telephone
6.
(A) Have any of the above listed (1) persons, or (2) companies owned, in whole or in part, by said persons, the applicant,
members of the organization, or any person having 20% or greater ownership interest in the organization had a mining
permit issued by Virginia or any other state revoked?
() Yes
() No
(b) If yes, give a brief statement of action.
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DMM-101
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7.
Have any of the persons listed above been convicted of violating any of the following sections:
45.1-161.292:33, 45.1-161.177, 45.1-161.178, and 45.1-161.233 as related to smoking in underground
coal mines or tampering with methane detection equipment in underground coal mines?
(
) Yes
(
) No
If yes, give name of person convicted
OPERATIONS INFORMATION
8.
Latitude
Longitude
9.
Mineral to be mined
Estimated annual production (in tons)
10. Type of Mine: (
) Open Pit
(
) Quarry
(
) Underground
(
) Dredge
(
) Dragline
(
) Other (specify)
11. COMPLETE EITHER A OR B
(A). List all MSHA Federal Identification Numbers issued to the applicant, members of the organization, or any person
having 20% or greater ownership interest in the organization.
Identification No.
Status
(B). List all names under which the applicant and either members of the applicant or any person having 20% or greater
ownership interest in the applicant operates a mine which has been issued a MSHA Federal Identification Number.
12. List any mining permits of any type held by the applicant in Virginia and the applicable permit identification numbers.
Issuing Authority
Permit No./Identification No.
13. Will explosive storage and blasting be required?
(
) Yes
(
) No
14. Number of employees each shift 1
2
3
15. Distance in feet to nearest inhabited building
16. Does the applicant have the personnel and facilities to provide safety training to its employees?
(
) Yes
(
) No
17. List any person with an ownership or leasehold interest in the surface land or minerals to be mined.
NAME
ADDRESS
Surface
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DMM-101
Rev 05/16
Surface
Mineral
Mineral
18. Specify source of applicant's legal right to enter and conduct mining operations on land covered by the permit:
Provide deed book number, page number, parties to the deed or lease, date of execution or provide a copy of the deed or
lease.
19. Please provide the following information for any contractors who will be working on the mine site
(attach additional sheets
as necessary).
Contractor’s Trade Name
DMM #
Business Address
Business Telephone
MSHA ID # (if available)
Address of Record
Service to be Provided
Where at the Mine Will the Work be Provided
Persons with responsibility for operating decisions:
Name
Address
Persons with responsibility for the health and safety of employees:
Name
Address
20. List rivers, streams, tributaries or water impoundments on or adjacent to permitted property.
pH adjacent
Name of waterway
to the mine
Tributary to
21. Specify how mine discharge and storm runoff water will be handled to minimize impact on any water courses. (Detail
drainage plan attached).
22. Specify any chemicals or hazardous materials (including petroleum products) which will be used on the mine site and
methods to be employed to prevent contamination of land and water resources on or adjoining permitted property.
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DMM-101
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OPERATION/RECLAMATION PLANS
23. Specify the materials which will be generated by mining operations and the plans for handling and disposal during
operations and reclamation.
TYPE OF MATERIAL
DISPOSAL METHOD
Overburden
Spoil/Waste Minerals
Scrap Metal
Scrap Tires
Used Oil and Lubricants
Trash and Debris
Hazardous Material
Buildings/Structures
PLANS: OPERATION/RECLAMATION/DRAINAGE PLAN
24. Describe in detail the method of mining, procedures for handling drainage, regrading, and vegetation during active mining
and upon completion (attach narrative).
CERTIFICATION/SIGNATURE
I,
, state that all the presentations contained in the foregoing
(Print Name)
application are true to the best of my knowledge; and that I am (an executive officer), (a general partner), (the sole proprietor), (a
legal representative), of the applicant, duly authorized to make this application on its behalf.
On behalf of the applicant, I hereby authorize the Virginia Division of Mineral Mining to conduct such safety/reclamation
inspections as it may deem necessary or as may be required by law on this mining operation.
Signature
Title
subscribed and sworn to, this
day of
,
(Month)
(Year)
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