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RE: MINING RECLATMATION PERMIT APPLICATION <br />COLO STAT. 34-32-112.10.8 <br />County Clerk & Recorder <br />DATE RECEIVED '7/5 <br />please print <br />615 Macon Avenue, Room 102 -Canon City, Colorado 81212 <br />Phone (719)2 76 -7336 Fax (719) 275 -1594 <br />I <br />NAME OF APPLICANT €k p <br />permit # C - �/- <br />DATE OF HEARING <br />NAM' OF CONTACT PERSON <br />D Phone # 7F4-62355 <br />e_ 'e (c :b6e_e36 -rte <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 />Clerk and R <br />FREM.ONT COUNTY <br />• date of dispostion clerk <br />G �� <br />