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Clerk and Recorder <br /> Katie E. Barr, County Clerk & Recorder <br /> 615 Macon Avenue, Roont 102 Canon City, Colorado 81212 <br /> Pho►re 719.276.7330 <br /> Fax 719.276.7338 <br /> katie.bar► a frerito►itco.coira <br /> RE: MINING RECLATMATION PERMIT <br /> APPLICATION COLO STATE 34-32-112.10.8 <br /> DATE RECEIVED_ f <br /> NAME OF APPLICANT <br /> PERMIT # <br /> DATE OF HEARING - ---� <br /> NAME OF CONTACT PERSON: <br /> /J - 6phone # <br /> please print <br /> Please check which box applies to your permit: <br /> I wish to be contacted 30 days after the hearing to pickup the application <br /> I do not wish to pickup the application 30 days after the hearing and <br /> herby give the clerk's permission to destroy <br /> Signature <br /> ® Date of Disposition Clerk <br /> 3/2l2016 VAJANTormsVeclamation fonn.doc <br />