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4/77 <br />MINED LAND RECLAMATION ~ III III III IIIIIII III <br />sss <br />ReQUlar (112) Permit Application Checklist <br />File 'rlo. 77-s ~ Name ~/Q,~~o ~w, _ Date of Filing (Completeness) : I 9 > <br />ITEi~i COMPLETE ADEOliATE COP4fENTS <br />Application Form <br />1. i+tame of operation <br /> <br />v <br />2. ;lame of applicant ~' <br />3. Address 6 phone (local offices) v <br />4. Address b phone (gen'1. offices) <br />5. Person to contact ~ V <br />_ <br />6. Parent corporation (if any) i <br />7. Surface owaers v <br />3. Pfineral owners i V <br />9. Type of mine/substance <br />.0. General location a elevation i v <br />.l. County ~ v <br />.2. Acreage t/ <br />.3. Fee / ~ ~ <br /> <br />.4. Present land use ~ ~/ I <br />.5. Surrounding land uses i ,i <br />.o. Proposed future use v <br />.7. Other mining permits `-'~ <br />.8. Signature v <br />.9. Prohibited Lands Statement ~ <br />'_laps S Exhibits <br />1. Legal description <br />2. Index map r~ <br />3. Pre-mining S mining plan map v <br />4. Piining plan - a) timetable I U <br />- b) depth 6 thickness of ore / I <br />0o y ---~_ • <br />