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4/i7 <br />~fINED LAND RECLAPfATION <br />Regular (112) Permit Application Checklist <br />File iQo. ~~- ~~{ Name C7cc, ~eyti¢~~ ~j, l Sties l ~ Date of Filing (Completeness): <br />ITEri COMPLETE ADEQUATE C01•IIdENTS <br />Application Form <br />1. Name of operation <br />v <br />2. Name of applicant <br />3. Address b phone (local offices) (/ <br /> <br />4. Address 6 phone (gen'1. offices) , <br />5. Person to contact ~ / ~ <br />6. Parent corporation (if any) <br />7. Surface owners <br />8. ?Lineral owners <br />, <br />9. Tvpe of mine/substance <br /> <br />C. General location ~ elevation <br />~ i <br />.1. County ~ / I j <br />.2. Acreage <br />3. Fee i I <br />4. Present land use I <br />, <br />i <br />.~. Surrounding land uses <br />/ ' <br />.6. Proposed future use <br />7. Other mining permits <br />8. Signature <br />.9. Prohibited Lands Statement <br />:taps 6 Exhibits <br />1. Legal description 1 / ~ ~ ~~~ <br />2. Index map <br />3. Pre-mining 6 mining plan map <br />i <br />4. Mining plan - a) timetable ~ <br />- b) depth 6 thickness of ore j <br />I <br />DOa ` <br />