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CCerk anc~?-LecorcCer <br />FREtifO~T COL~tiTY" <br />Ivor:ia Hatfield <br />Counr Clerl' R Recordu <br />61 i Macon Arznuz, Roont 103-Canon Cin•, Colorado 31312 <br />Phone (7t9) 276-7,3b Fa.~ (719) 375-1i9~ <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED ` v <br />NAME OF APPLICANT <br />permit #_ <br />DATE OF HEARING ~Z( ~ '/`(~ [ i(i`~ <br />NAME OF CONTACT PERSON <br />anode <br />please print <br />Please check which box applies to your permit:. <br />Q I wish to be contacted 30 days after the hearing to pickup the application <br />I do not wish to pickup the appliption 30 days after the hearing and herby <br />give the clerk's office permission to distro~ <br />• date of dispostion olerk <br />