Laserfiche WebLink
7/7F III IIIIIIIIIIIII III • <br />REGULAR 112 APPLICATION <br />APPLICATION CHECKLIST <br />Sr;.1e ;ok ~G:b bo~+i <br />NAME ~,n.,fcin p;t" FILE /f /- Q <br />COMPLETE (FILED) DATE lTan. ~T l9F/ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br />3. Address 6 phone, local <br />4. Address E phone, general <br />5• Person to contact <br />~G <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners <br />9• Source of Legal Right-to-Enter <br />10, Type of MineiSubstance <br />~~ <br />11, General Location 6 Elevation ~\ <br />12. County <br />~~ <br />13. Acreage <br />~~ <br />14. Fee <br />15. Present Land Use <br />16, Surrounding Land Uses <br />~C <br />17. Proposed Future Use <br />18, Unpermitted Mining Operations <br />19. Affected Lands iN~~ <br />20. Signature <br />(over) <br />