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4/77 • <br />.MINED LAND RECLAMATION <br />Regular (112) Permit Application Checklist <br />File 2io.7~ 3KSName~~}~ r3n.s,c. T~~ l.~Sfcti ~5 Date of Filing (Completeness) <br />T,.., ~ <br />ITEPf COMPLETE ADEQUATE COPIMENTS <br />Application Form <br />1. flame of operation <br />2. name of applicant <br />3. Address 6 phone (local offices) <br />4. Address 6 phone (gen'1. offices) i <br />5. Person to contact <br />6. Paren[ corporation (if any) <br />7. Surface owners ~ <br />3. t•iineral owners / <br />~ v <br />i <br />9. Type of mine/substance <br />0. General location S elevation ~ ~ <br />, / <br />1. County ~ v <br />2. Acreage <br />3. Fee ~ ~~ <br />4. Present land use ~ <br />5. Surrounding land uses <br />6. Proposed future use <br />7. Other mining permits <br /> <br />8. Signature / ~ <br />v <br />9. Prohibited Lands Statement <br />'aps b Exhibits <br />1. Legal description p <br />v <br />2. Index map <br />_. Pre-mining 5 mining plan map <br />i <br />4. Paining plan - a) timetable ~ l / <br />v <br />- b) depth b thickness of ore <br />ooav <br />