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4/77 <br />~ILTTED LAND RECL,A2tATI0N • <br />Regular (i12) Permit Application Checklist <br />III IIIIIIIIIIIIIIII <br />sss <br />File clo. 'J'f'3y7 Name_ ~~`/ ~,~,.~•L Date of Filing (Completeness) <br />ITE'i~i COMPLETE ADEQUATE COPIMENTS <br />Aoplica*_ion Form <br />1. Name of operation <br />/ <br />/ <br />2. ;lame of applicant ~ <br />3. Address ~ phone (local offices) <br />4. Address 6 phone (gen'1. offices) ~ / <br />5. Person to contact ~f <br />6. Parent corporation (if any) I/ <br />7. Surface owners <br />3. ?Lineral owners ,~ <br />~ <br />- <br />9. Type of mine/substance - <br />0. General location 6 elevation ~~ <br />.1. County ~f I ~ <br />.2. Acreage ~ / <br />.3. Fee !, ~ <br />i <br />.4. Present land use ~/ <br />.f. Surrounding land uses 1 ~ , <br />6. Proposed future use ~/ <br />7. Other mining permits <br />8. Signature / <br />.9. Prohibited Lands Statement <br />'tap <br />1. s & Exhibits <br />Legal description <br />2. Index map ~ ~ , <br />3. Pre-mining 6 mining plan map <br /> <br />4. i <br />Pfining elan - a) t+ etable ~ <br />~ <br />~ ~ <br />, <br /> - b) h b t ness of ore ~ ~ <br />bndv <br />-, <br /> <br />a <br /> <br /> <br />