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I' <br />~1 <br />~:orrna Hacfizld <br />Coun~' Clzrl & Rzcordzr <br />C~er~ c~ncf-R,ecorc~er <br />FR;=~TO~Ir co~-~r~~ <br />6 f 5 iV[acon gvznuz, Room 102-Canon Ciry, Colorado 31212 <br />Phonz (7[9} 376-7336 Eat (719} 275-I59~F <br />RE: MINING RECLATMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />DATE RECEIVED <br />NAME OF <br />permit # <br />d fLe~v2a T rl~w~ <br />DATE OF HEARING <br />NAME OF CONTACT PERSON <br />please prln~ <br />Please check which box applies to your permit: <br />I wish to be contacted 30 days after the hearing to pickup the application <br />~ I do not wish to pickup the application 30 days after the hearing and herby <br />give the clerk`s office permission to distroy <br />• date of dispostion clerk <br />