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4/i7 ~ ~ <br />D LAND RECLAh7ATI0N <br />Regular (112) Permit Application Checklist <br />III IIIIIIIIIIIII III <br />sss <br />File 270. Name Date of Filing (Completeness): <br />ITE2•f COMPLETE ADEQiJATE COZ4fENTS <br />Application Form <br />1. Name of operation <br />~i <br />2. name of applicant <br />(: <br />3. Address ~ phone (local offices) ~ <br />t <br />4. Address 5 phone (gen'1. offices) <br />5. Person to contact ~ ~ <br />6. Parent corporation (if any) i <br />7. Surface owners <br />8. PLineral owners <br />9. Type of mine/substance <br />L0. General location 6 elevation ~ <br />L1. County ~ I ~ <br />L2. Acreage <br />L3. Fee ~ i <br />L4. Present ].and use ! <br />'~~. Suzrounding land uses <br />.6. Proposed future use <br />.7. Other mining permits <br />.8. Signature <br />.9. Prohibited Lands Statement <br />'Maps 6 Exhibits <br />1. Legal description <br />2. Index map <br />3. Pre-mining 6 mining plan map `~' <br />4, riming plan - a) timetable I l <br />- b) depth 6 thickness of ore <br />• <br />' j <br />I <br />bodv <br />