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4 / i 7 ~II3ED LAND RECLAPfATION ` III III I II I II IIII III <br />sss <br />Regular (112) Permit Aoplication Checklist <br />File ido• 3~1 Name =',~.eQ,(, {~o„S~ c ~"u-~u5g of Filing (Completeness): <br />r.A ~ . <br />ITE2•f COMPLETE ADEQUATE COP4fENTS <br />Application Form <br />1. flame of operation / <br />v <br /> <br />2. Name of applicant / <br />~/ <br />I <br />3. Address E phone (local offices) L~ <br />4. Address b phone (gen'1. offices) J <br />5. Person to contact <br /> <br />6. Parent corporation (if any) <br />V i <br />7. Surface owners I /~ { <br />8. Piineral owners <br />i <br /> <br />9. Type of mine/substance // <br />v <br />0. General location 6 elevation ~ 7/ <br />1. County i ~ <br />.2. Acreage { <br />.3. Fee ~ ~~ I ~ <br />4. Present land use { ~~ ~ <br />.~. Surrounding land uses ~ v <br />6. Proposed future use <br />7. Other mining permits <br />.8. Signature <br />.9. Prohibited Lands Statement <br />'laps b Exhibits <br />1. Legal description <br />2. Index map <br />3. Pre-mining & mining plan map <br />i <br />4. Paining elan - a) timetable ~ <br />- b) depth b thickness of ore <br />/~! I <br />,, <br />7 <br />DOQy <br />