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~L~lED LAND RECLAMATION <br />4/i7 ~ III IIIIIIIIIIIIIIII <br />sss <br />Regular (112) Permit Aoplication Checklist <br />File 2Io.~7.5a2 Name waX~~ ~t195. ~~ Date of Filing (Completeness) <br />ITEL•S ~~ ~~`~ COMPLETE ADEQUATE COZ4fENT5 <br />Application Form <br />1. Name of operation <br />~~ <br />2. ;lame of applicant / <br />3. Address E phone (local offices) <br />4. Address 6 phone (gen'1. offices) <br />5. Person to contact ~ J <br />6. Paren[ corporation (if any) <br />7. Surface owners [/ <br />3. t!ineral owners <br />i <br />9. Type of mineJsubstance <br />O. General location & elevation <br />1. County ~ ~~ <br />2. Acreage C/ <br />3. Fee i / I ' <br />4. Present land use ~ / <br />i <br />~ <br />5. Surrounding land uses !~ <br />.6. Proposed future use ~ ~ <br />7. Other mining permits <br />8. Signature ~~ <br />.9. Prohibited Lands Statement ? s°fb ~~IYO~yM: <br />'laps S Exhibits <br />1. Legal description <br />?. Index map <br />3. Pre-mining 6 mining plan map <br />4. Mining plan - a) timetable I `~ <br />- b) depth 6 thickness of ore <br />v I ~N ,,,/~ <br />DOay <br />