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` 4/77 III III III IIIIIIIIII • /' <br />• MINED LAND RECLAZ`tATION <br />v~_ .~ Regular (112) Permit Application Checklist ~Q--~ ~7 7 ~I"/~1' <br />File ~Io / ~-~~•~ game (//y~~N ~~2~~D~ ~DQP Date of Filing (Completeness) : ~n /-~~- 77 <br />ZTBcf COMPLETE ADEQUATE COt•Il`tENTS <br />Application Form <br />1. came of operation <br />~~ <br />~~ <br />2. Name of apolicant /ice // <br />3. Address 6 phone (local offices) V- y <br />4. Address S phone (gen`1. offices) ~~ ~ <br />5. Person to contact <br />_ ~ ~~ <br />~ !~~ <br />6 <br />Parent corporation (if any) <br />. <br />7. Surface ocmers ~~ ~' <br />I <br /> <br />8. Ptineral owners <br />9. Type of mine/substance <br />L~ <br />~(i-~ <br />~~~ <br />/~ - <br /> <br />L//L - ~//I;~. <br />- <br />0. General location & elevation i ~~ J <br />- ~-- <br />1. County i /~-- - <br />I ~~ <br />2. Acreage r ~~ ~ m~fP /~ ~2 d <br /> <br />3. Fee i ~" j T i <br />~~ ~ <br />~ ~ ~~ ~ /~ F'- <br />4. Present land use ~ ~~I <br />i ~ I <br />~ <br />5. Surrounding land uses j ~~ ~~ ~ <br />6. Proposed future use (/ ~ ~ <br />7. Other mining permits ~~ <br />8. Signature ~- - <br />9. Prohibited Lands Statement / <br />~/- ~~ <br />~Ia7~5 Fi EXi11b 1tS <br />1. Legal description <br />~- "/ "/ '~ <br /> <br />2. ZndeX map ~~~ ~ <br /> <br />3. Pre-mining & mining plan map <br />~ . .. <br />'- <br />4. I•lining plan - a) timetable ~ ~- <br />- b) depth 6 thickness of ore <br />I <br /> <br />7 <br /> <br />uuuy <br />