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4/77 • ��f �I��III�III����II <br /> OMLNED ULM RECLAMATION <br /> Regular (112) Permit Application Checklist sss <br /> File No. 761-710 Name F ta- -i oy i, Date of Filing (Completeness) : <br /> ITMq MTLETE ADEQUATE COr¢IENTS <br /> Application Form <br /> 1. Name of operation <br /> 2. Name of applicant <br /> 3. Address & phone (local offices) T <br /> 4. Address & phone (gen' l. offices) I <br /> 5. Person to contact v <br /> 6. Parent corporation (if any) <br /> 7. Surface o%-aers <br /> S. i�Lineral owners <br /> i <br /> 9. Type of mine/substance <br /> 10. General location & elevation I <br /> 11. County <br /> 12. Acreage v� l j <br /> _ I <br /> — <br /> 13. Fee <br /> 14. Present land use <br /> 1-5. Surrounding land uses I // <br /> 16. Proposed future use <br /> I <br /> 17. Other mining permits <br /> i <br /> 18. Signature <br /> i <br /> 19. Prohibited Lands Statement <br /> Maps & Exhibits <br /> 1. Lagal description v/ <br /> 2. Index man <br /> 3. Pro-mining & mining plan map v <br /> 4. *Lining ?Ian - a) timetable <br /> - b) depth & thickness of ore <br /> L_,.. <br /> G/ � <br />