Laserfiche WebLink
.~ ~ _ ` • iii iiiiiiiiiiiiiiii <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name riw ~c~ <br />Special 10-Day (111) Complete Filed Date t <br /> <br />File No f1~~ `0~ <br /> <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />X <br />~/ <br />/\ <br />2. Name of Applicant/Operator ,/ <br />l <br />` ~ <br />3. Address & Phone (Local) x <br />4. Address & Phone (General) <br />5. Person to Contact ~ <br />6. Surface Owners <br />7. Mineral Owners <br />X `/ <br />7~ <br />8. Source of Legal Right-To-Enter X <br />9. Type of Mine/Substance <br />10. General Location & Elevation ~ <br />11. County ~ <br />12. Acreage ~ ~ <br />13. Fee ,Y <br />/\ ~ <br />14. Present Land Use ~~~~~ ? <br />15. Proposed Future Use <br />k ~.w:("-~,• 5Lp 7 <br />r~ <br />16. Signature <br /> <br />~1 <br />