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4/i7 ~ III IIIIIIIIIIIIIIII <br />~NED LAPlD RECL,APfATION <br />Regular (112) Permit Application Checklist <br />File 2Io. ~~- ~ I I Name C ~ , t ~ C~.~, ~, ~-(~ Date of Filing (Completeness) <br />ITEi•1 COMPLETE ADEOliATE COP4fENTS <br />Application Form <br />1. Game of operation (/ <br /> <br />2. Name of applicant <br />3. Address E phone (local offices) <br />' <br />4. Address 5 phone (gen <br />1. offices) <br /> <br />5. Person to contact <br />6. Parent corporation (if any) I <br /> <br />7. Surface owners r c.: c ~ j cr r r .n ~ ~ .• aVs <br />~ ``~°"' •~ ~ ~ `t ~QJ~,„; <br /> ~J'CK GW~.~~J,~ <br /> <br />3. Piineral owners I o(G'a CYNt OW.n CJS S <br />NOS pPJ ~,.,1 ~ .yr e.. <br /> I fi'v: N.Q/9 <br />9. Type of mine/substance r/ <br />0. General location & elevation ~ (~ <br />1. County ~ I/ I I <br />.2. Acreage <br />I L~ ~ <br />3. Fee I ~ ~ ~ <br />4. Present land use ~ /~ <br />.~. Surrounding land uses <br />.o. Proposed future use <br /> ~~ <br />.7. Other mining permits <br />.8. Signature <br /> / <br />v <br />.9. Prohibited Lands Statement <br />'laps 6 Exhibits <br />1. Legal description <br /> ~/ <br />2. Index map <br /> <br />I <br />l <br />~ ~ccr Cad <br />f'Id <br />~ <br />an map <br />3. Pre-mining b mining p c vti <br />~., <br />~u <br /> <br />4. Paining plan - a) timetable I <br />I ~'v~ .eJ <F <br />~ ~•^~"~e'^~'° ~ <br />- b) depth 6 thickness of ore r ' <br />1 i '"` ¢" "~ ~ L <br />cu.. {`i cf .~~. 'tl ~~. ~ <br />y.oW ~~ <br />bo Cy <br />