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(it. .parc\c74. <br /> i,„ . i,;,,,-,, _ :,,aClerk and Recorder <br /> ,� Katie E. Barr, County Clerk & Recorder <br /> (..1., <br /> ` ;,.tJ 615 Macon Avenue, Room 102 Canon City, Colorado 81212 <br /> Phone 719.276.7330 <br /> Fax 719.276.7338 <br /> katie.barr afrennontco.conn <br /> RECEIVED <br /> RE: MINING RECLATMATION PERMIT OCT 2 s 7fl„ <br /> F- :1?`a7Y <br /> APPLICATION COLO STATE 34-32-112.10.8 .L-..:;rA . 71�=R <br /> RECEIVED <br /> DATE RECEIVED ! O •cOJ "7 Nov , 2 70t7 <br /> FREMNAME OF APPLICANT ,. ,� &It_a 4. CLERK&Fl^tiJ i R <br /> �rD*a <br /> PERMIT # 4 hi J 9 ' O IQ ko.).-o r.oN <br /> DATE OF HEARING A/,r� <br /> NAME OF CONTACT PERSON: <br /> `7 'e K1 C4 phone # 9?-/ -e-//g <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 3-0-days after the hearing and <br /> herby give the clerk's permission to destroy 90//010 <br /> Signature _____ 14,,A ,...--- <br /> • Date of Disposition Clerk <br /> 3/2/2016 V.UAN\Forms\reclamation form.doc <br />