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4177 ~, _ _ _ <br />•MLYED LAND RECLAPIATION • III III~IIIIII~IIIII <br />Regular (112) Permit AapLication Checklist sss <br />Pile To. ~j7~Z67vame ~~Q.rO C'pc.c~y Date of Filing (Completeness) <br />ITEif CO~LETE ADEQUATE COr1hfENTS <br />Application Form <br />1. Name of operation <br />2. :Tame of applicant ~j~ <br />3. Address ~ phone (local offices) <br />4. Address S phone (gea'1. offices) i <br />5. Person to contact <br />6. Parent corporation (if any) <br />7. Surface owners 6~ <br />3. .fineral owners <br />I <br /> <br />9. Type of mine/substance <br />~~ _ <br />.0. General Location & elevation <br />.l. County ~ <br />.2` Acreage ~ ~ I y <br />.3. Fee ( ! ~ - +~-- <br /> <br />.4. Present land use ~ /jam i I <br />~ <br />.5. Surroundiao land uses <br />.6. Proposed future use ~ <br />i <br />.7. Other mining permits <br />.8. Signature ~ (~~ <br />.9. Prohibited Lands Statement <br />`laps & Exhibits <br />1. Legal description I / <br />/v/ <br />2. Index map <br />3. Pre-minin b minin p <br />g g Plan ma <br />V <br />I ~VC2c~ eLPivn,f;~ . <br />tto-~er~eelsi.,+b~~~-imp <br />5' <br />~" <br /> <br />4. Mining plan - a) timetable <br />( eY <br />fVe~ ~Y> <br />= <br />~,~,;~,~,py~ e~{1 ~~„~~~ <br />- b} depth 5 thickness of ore .~ <br />bony <br />