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4/77 <br /> MINED LAND RECLAMATION <br /> Regular (112) Permit Application Checklist <br /> File i,Io. j(, 17_5,rName � �� , �� Qom; Cc., . Date of Filing (Completeness) : <br /> ITE14 COMPLETE ADEQUATE COMKENTS <br /> Application Form <br /> 1. Name of operation <br /> 2. Name of applicant <br /> 3. Address 6 phone (local offices) <br /> 4. Address S phone (gen'l. offices) / <br /> 5. Person to contact (/ <br /> 6: Parent corporation (if any) <br /> 7. Surface owners / <br /> S. Mineral owners !/ <br /> i <br /> 9. Type of mine/substance <br /> 10. General location S elevation <br /> i <br /> 11. County <br /> 12. Acreage <br /> 13. Fee <br /> 14. Present land use <br /> 15. Surrounding land uses <br /> 16. Proposed future use <br /> 17. Other mining permits <br /> 18. Signature " <br /> 19. Prohibited Lands Statement <br /> :Maps b Exhibits <br /> 1. Legal description <br /> 2. Index map <br /> 3. Pre-mining S mining plan map <br /> Mining plan - a) timetable <br /> - b) depth 6 thickness of ore L j <br /> i <br /> body <br />