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MINED LAND RECLAMATION <br />4/~~ i • III1111111111111111 <br />Re]~ular (112) Permit Application GhecY1 ist <br />File ?]o. f7~ ~~` Name }.~a~k~ Date of Filing (Completeness): ~f 7 <br />ITE`i? COMPLETE ADEQUATE COPII9ENTS <br />Application Form <br />1. iQame of operation <br />2. Name of applicant <br />3. Address fi phone (local offices) <br />4. Address fi phone (gen'1. offices) If <br />i <br />5. Person to contact ~~/ <br />6. Parent corporation (if any) ~ <br />7. Surface owners ~ { <br />3. PLineral owners ]/ <br />i <br />9. Type of mine/substance <br />.C. General location fi elevation f <br /> <br />.1. County r <br />~~ , <br />.2. Acreage <br />3. Fee ~ ~/ ~ <br />.4. Present land use ~/ C <br />.5. Surrounding land uses ~ ,~ 4 <br />.o. Proposed future use <br />.7. Other mining permits ~/ <br />.~. Signature / <br />.9. Prohibited Lands Statement / <br />`taps 6 Exhibits <br />1. Legal description <br /> <br />V <br />2. Zndex map <br />3. Pre-mining S mining plan map ~ I <br />4. Pfining plan - a) timetable I V <br />- b) depth 6 thickness of ore j <br />I <br />uuu <br />/, <br />i <br />