Laserfiche WebLink
• iiiiiiiiiiiiiiuiii • <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name Lcv~ ,,c~ ~ "`PPy <br />Special 10-Day (111) Complete Filed Date <br /> <br />~ <br /> <br />File No. M-b5 ~ <br /> <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />,/ <br />/ <br />/ <br />2. Name of Applicant/Operator / •/ <br />3. Address & Phone (Local) ~ '/ <br />4. Address & Phone (General) `/ ,/ <br />5. Person to Contact ~/ <br />6. Surface Owners <br />7. Mineral Owners `/ / <br />8. Source of Legal Right-To-Enter / <br />V <br />~/ v rbcl <<~~rem zn <br />W•4`~ nom}, C. r~.T <br />9. Type of Mine/Substance ~/ <br />/ <br />10. General Location & Elevation / / <br />11. County ~/ / <br />12. Acreage / / a ~~~~ <br />13. Fee. / / <br />14. Present Land Use / V <br />15. Proposed Future Use / / <br />16. Signature ~ <br />~z <br />P1~ <br />