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E°'h`p" `S.Y c'4'Paf` Y.. : 9=^ 2re ~_. ~r <br />Name of mill (if any), eater and capacity--= __-- - ----- --------------------------- <br />r 1 <br />----------- ------- - ~ S <br />~c_'~z------- --- ---------------- ---------------------------- <br />---..~4---- - ---C-~-7--------------- ---:- ---- -=--- -. <br />"' , Gharapter~of'surfa~e impropemente_ __ ~ _ -, - `~~~-~~~` <br />Amount and character,of under-ground development__ ~ "`"~ ~~`'`""~~ <br />Signed--------- ----------------------~%~------' <br /> <br /> <br />