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4/77 <br />MINED LAND RECLA:IATIOA• , <br />Regular (112) Permit Application Checklist <br />III IIIIIIIIIIIIIIII <br />File ~Io. 77-210Name Cmsl`/< C~hc:r {-e Date of Filing (Completeness): <br />I~t Sh ~r.' um.^v <br />ITEii COMPLETE ADEQUATE COPASENTS <br />Application Form <br />1. :lame of operation <br />2. ;lame of applicant <br />3. Address 6 phone (local offices) <br />4. Address b phone (gen'1. offices) <br />5. Person to contact <br />_ ~ <br />i <br />o. Parent corporation (if any) <br /> <br />7. Surface ocrsers ~~e,~c.~e,,. ~,~<~~ a. <br />~ 3`° `" ~ ""tom '"°~ ~""" <br />a+e•< oLLH FV s <br /> <br />3. Piineral owners <br />i ~ ~4C<v. ~u+N~P/J s~~ <br />64t e •f p<~~~f ~'c` <br />9. Type of mine/substance <br />0. General location ~ elevation ~ / <br />.1. County i t/ I ~ <br />.2. Acreage <br />3. Fee <br />i <br />.4. Present land use ! ~ ~ <br />.f. Surrounding land uses <br />.6. Proposed future use <br />.7. Other mining permits <br /> <br />.8. Signature / <br />(/ <br />.9. Prohibited Lands Statement <br />:Maps S Exhibits <br />1. Legal description <br />2. Index map V <br /> <br />3. Pre-mining b mining plan map mai•lcrd ca.,c"~d~..q~ <br />4. Ptining plan - a) timetable I ,vi m ~ I: < ~ ~ ~~,{~d~„c <br />- b) depth 6 thickness of ore ~ v~ s,, (<o ~ ~ oµ E';~rQu <br />.~ <br />~~ <br />3~ <br />',u r <br />f:~ ~ <br />~~~v <br />