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4/77 ~ w ~ <br />rD LAND RECLAMATION ~, <br />Regular (1.i7} Permit Application Checklisl~' <br />File i~io. ~~~ Name /s.~<< - Ltnwrr jE"ra~ P:~ Date ofj,r~£ling (Completeness) <br />ITEi•1 G ADEQUATE COPfh~NTS <br />Application Form <br />I. flame of operation <br />2. ,lame of applicant <br />3. Address fi phone (local offices) <br />4. Address fi phone (gen'1. offices) ~ <br />5. Person to contact ~ f <br />6. Parent corporation (if any) / ~ <br />7. Surface owners / <br />$. ,4ineral owners / <br />i <br />4. Type of minelsubstance / • <br />0. General location fi elevation <br />1. county j / ~ Pra„cYS I <br />.2. Acreage ~ ,/ <br />.3. Fee <br />/ 1 <br />~ <br />4. Present land use ~ a,~~ <br />.5. Surrounding land uses ~ ~' <br />.6. Proposed future use ~/ <br />.7. Other mining permits ~ / <br />.8. Signature ,~ <br /> <br />Q. Prohibited Lands Statement / <br />/ <br />Mans fi Exhibits <br />i. Legal description <br />,/~ <br />2. Index man ./~ <br />3. Pre-mining fi mining plan map I / <br />~ ~ <br />4. PLining plan - a) timetable / <br />- b) depth fi t'nickness of ore _ . L ~ ~~ 1 j am' <br />