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4/77 <br />MINED LAND RECLAZ•fAT20N <br />Regular (112) Permit Application Checklist <br />File :Io. ~7 !~/ Name Ccw'~~5 ~~ow~ Date of Filing (Compl2teaess): <br />Mtr,. /{~qa <br />ZTEi~f COMPLETE ADEQtATE COPII~tENTS <br />Application Form <br />1. Name of operation <br />2. :lame of applicant <br />3. Address ~ phone {local offices) <br /> <br />4. Address b phone (gen'1, offices) <br />~ ~ / <br />! I <br />~ <br />- <br />5. Person to contact <br />~ - r <br />__ <br />6. Parent corporation (if any) <br />7. Surface owners ~ <br />8. iiineral owners <br />i <br />9. Type of mine/substance <br />0. General location 5 elevation ~L~ <br />1. County ~ <br />.2. Acreage ~ <br />3.' Fee ~ ! <br />~ <br />.4. Present land use ! I <br />i <br />.5. Surrounding land uses <br />I <br />.6. Proposed future use ( <br />I <br />7. Other mining permits <br />.8. Signature <br />.9. Prohibited Lands Statement ~~ <br />`laps 6 Exhibits <br />1. Legal description <br />2. Index map <br />3. Pre-mining b mining plan map i k)~~ey <br />4. Mining plan - a) timetable ~ ~,,,,;}~,~ k~,,,r~.a.lr;~~ <br />- b) depth S thickness of ore ~- ~ <br />body <br />