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<br />~~I I~~II~II~I~~~ I~~ <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Soti{h wrsf Ready-M;r, Xn~. <br />Regular 112 Application Name °R~.G Pit -~rd A File iVo.H-~5-o1r•P' <br />Complete Filed Uate ~7'.ch, !6 /`r~6 <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> <br />~ <br /> <br />X <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />ti. Mineral Owners <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Substance <br />11. General Location & Elevation <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed future Use <br />