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fur <br /> Clerk and Recorder <br /> Katie E. Barr, County Clerk & Recorder <br /> '�• � 615 Macon Avenue, Room 102 Canon City, Colorado 81212 <br /> Phone 719.276.7330 <br /> Fax 719.276.7338 <br /> katie.barr@fremontco.com <br /> fremontco.com <br /> RECEIVD <br /> RE: MINING RECLATMATION PERMIT OCT ° '9" <br /> F- ,_*QTY <br /> APPLICATION COLO STATE 34-32-112.10.8 =- _= iJ t2ER <br /> RECEIVED <br /> DATE RECEIVED I6 NOV 0 2 7517 <br /> FREi1�D31 +TY <br /> NAME OF APPLICANT J7 a ,L ci )� � dvs- CLERK& :;ER <br /> PERMIT # f 9 '( O IQ ►�vPL•c-A.rN ry <br /> DATE OF HEARING A/,t <br /> NAME OF CONTACT PERSON: <br /> "Ke rl K1 C j phone # CNa- 14g <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 /> 2( I do not wish to pickup the application 30-days after the hearing and <br /> herby give the clerk's permission to destroy ga/'J410 <br /> Signature <br /> • Date of Disposition Clerk <br /> 3/2/2016 V:VAN\Forms\reclamation form.doc <br />