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4/77 <br />L^1ED LAND RECLAPIATION <br />Regular (112) Permit Application Checklist <br />File ado. 5~ Name ~Q- / C. d t~-~-e Date of Filing (Completeness) : `/ Z~ 7] <br />7'7-2z~- <br />iTEi•1 COMPLETE ADEQUATE COP1PtENTS <br />Aoplication Form <br />1. Name of operation <br /> <br />2. Name of applicant / <br />~/ <br />3. Address 6 phone (local offices) <br />4. Address b phone (gen'1. offices) <br />J <br />5. Person to contact ~ <br />6. Parent corporation (if any) I ~ i <br />7. Surface owners <br /> <br />3. Piineral owners / <br />v <br />i <br />9. :ype of mine/substance <br />0. General location 6 elevation ~ ~ <br /> <br />1. County ~ , / <br />!/ <br />I <br />I <br />2. Acreage <br />- <br />3. Fee ~ ~ <br />4. Present land use ! <br />5. Surrounding land uses <br />6. Proposr_d future use <br />7. Other mining permits ' <br />S. SignaUare <br />.9. Prohibited Lands Statement <br />'.]aps fi Exhibits <br />1. Legal description <br />v <br />2. Index man <br /> <br />3. Pre-mining 6 mining plan map ~~ <br />i <br />w. Paining; plan - a) timetable ~ <br />- b) depth ~ kness of ore <br /> <br />~- <br />body <br />