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VOTE <br /> MANE FREEDOM COUNT <br /> .+ram <br /> tare e&Ak and q""du <br /> MINING RECLAMATION-PERMIT APPLICATION <br /> CRS 34 3Z 112 (10;)(a) _(Filing On <br /> Applicant Nam t Date Received _ <br /> Permit # <br /> Date of the-Hearing <br /> f _ <br /> contact Name and Phone #: <br /> Name. 1 `�a (\�U n Phone # -7� _ 1 <br /> WE x <br /> sg18 <br /> t <br /> please print <br /> Please check which box applies to your permit: <br /> ❑ I wish to be contacted 30 days after the hearing to picku{ �, �afation <br /> U <br /> cs 3 fox <br /> SAY; YYr a sinz'n � £ 4 <br /> ❑ I do not wish to pickup the; application O'tfflWys;'after thte 1 `Itg and I hereby give <br /> 't <br /> the Clerk's Office permissi6nf o <br /> ; . . <br /> Signatiure- <br /> Accepting Clerk. A Date of FilinOLLIE <br /> jtift <br /> r <br /> gwmont eount* Uw& and 5&eaxden <br /> S.Macon am Suite 1021103 <br /> eaiwn eit*,eV 81212 (719)-276-7332 jwtin.gnawMam@ wwntca-c m <br />