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4/77 ~FGXC.dAC("~~V ~ 7~ <br />MINED LAND RECLATIATION M <br />Regu`la~~r (112) Permit Application Checklist <br />File :do.1T"/~d Name '~.~5 ~or+nC.c~- Date of Filing (Completeness) : l 2 ~~ <br />ITEit CO:~LETE ADEQUATE COT)rtENTS <br />Application Form <br />L Name of operation <br />/ <br />~- <br />2. Vame of applicant / ~- <br />3. Address E phone (local offices) ~' (/" <br />4. Address 6 phone (gen'1. offices) / ~~ <br />5. Person to contact ~,/ ~ ~~ <br />6. Parent corporation (if any) ~~ I <br />7. Surface ocmers ~ ( . - I <br />I <br />i <br />SMineral ocmers I / I ~~~ <br />9. Type of mine/substance / L/~ <br />0. General location & elevation / <br />i.V //~ I <br />1. County ~ ~O 6f~ C. ~- <br />.2. Acreage ~ 2 / <br />3. Fee ~ /(/ ~ f~-~ <br />--- <br />- <br />.4. Present land use ~ t/• i ~-~~ r <br />.5. Surrounding land uses ~ ~/' ~-~' <br />.6. Proposed future use ~ ~ ~ 'L-'~- <br />.7. Other mining permits ~ ~ <br />.8. Signature ~ l <br />.9. Prohibited Lands Statement ~- <br />_ <br />Gaps & Exhibits <br />1. Legal description <br /> <br />/ ~ <br />~ <br />~ / ~ <br />~~ /` //r <br /> <br />/L/ _ <br />-TT -~'[" <br />2. Index map / ~_ 1 <br /> <br />3. Pre-mining & mining plzn map <br />f r'.: <br />,~~ <br />G+r~ <br />4. Mining plan - a) timetable I / I <br />-`~'-' <br />~ <br />- b) depth & thickness of ore it ~ <br />; <br />G~ <br />body <br />