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4/77 <br />"ILNED LAND RECL.9.*fATIO:v <br />Regular (112) Permit Aflclication Checi;list <br />File :]o. 77-30~ Irame ~„~(o~~c.dc, Li zw Date of Filing (Completeness): <br />ITEi~f COPiPLETE ADEQUATE COt1MENTS <br />Application Form <br />I. name of operation v <br />2. .dame of applicant L~ <br />3. Address ~ phone (local offices) ~ <br />4. Address S phone (gen'1. offices) ~ / <br />i <br />5. Person to contact ~ ~ <br />I ~ <br />ti. Parent corporation (if. any) ~ I <br />1 <br />7. Surface owners ' ~ I <br />I I <br /> <br />8. *iineral owners <br />i I <br />9. ?ype of mine/substance <br />0. General location & elevation i <br /> <br />1. County ~ I <br />~ i <br />/ <br />2. Acreage ~ ~/ <br /> <br />I <br />3. Fee <br />I ~ <br />I <br />I <br />~ <br />/ <br />4. Present '_and use ~ v I <br />~ <br />5. Surrouncing land uses <br />~/ <br />6. Prcposed future use <br />7. Other mining percaits (/ <br />8. Signature ~ NHS 5'`d'""'~".v <br />9. Frohibited Lands Statement ~ ~ <br />r/ J <br />`aps & Exhibits <br />1. L.ega1 description <br />-- <br />?. Index map ~ <br />' I <br />3. Pre-mining 6 mining plan map f <br />-- i <br />4. Itining plan - a) timetable ~ <br />~ <br />- b) depth ~ ckness of ore <br />1 <br />I <br />I <br />1 <br />1 <br />1 <br />I <br />1 <br />Z <br />v <br />body <br />