Laserfiche WebLink
;a • <br />Limited Impact (110) <br />Special 10-[lay (111) <br />DII IISII~SISIS~IIID <br />MINED LAND RECLAMAItun <br />Application Worksheet/Checklist <br />Name ~~.~~ ~, ps l eit.~~ti~ File No. ~t'1- c-1i1~ <br />Complete Fi d Date l~%~0/9~~ <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. Name of Applicant/Operator <br /> J <br />3. Addre<_,s & Phone (Local) <br /> <br />4. Address & Phone (General) <br />5. Person to Contact <br /> <br />6. Surface Owners / <br />7. Mineral Owners <br /> <br />8. Source of Legal Right-To-Enter J <br />9. Type of Mine/Substance , <br /> <br />10. General Location & Elevation <br /> J <br />11. County <br /> <br />12. Acreage <br />13. Fee <br />14. Present Land Use <br /> <br />15. Proposed Future Use / <br />16. Signature <br /> <br />