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D LAND RECLAMATION <br />4/i7 ~ • III III'lllll'llllll <br />_. 999 <br />ReRU1ar (112) Permit Application Checklist <br />File ido. 7~- 30~/ Name s'w~ ~,/• Go yPovc 4icx~ate of Filing (Completeness) <br />ITEi•1 COMPLETE ADEQUATE COr4fENT5 <br />Application Form <br />1. Name of operation <br />2. Name of applicant <br />3. Address 6 phone (local offices) <br /> <br />4. Address 6 phone (gen'1. offices) / <br />v <br />5. Person to contact <br />_ <br />6. Parent corporation (if any) ' / <br />v <br />7. Surface owners <br />3. Piineral owners <br />i <br /> <br />9. Type of mine/substance / <br />v <br />0. General location 5 elevation ~ <br />1. County <br />.2. Acreage l/ <br />.3. Fee ~ ~ <br />.4. Present land use <br />.~. Surrounding land uses <br />.6. Proposed future use <br />.7. Other mining permits <br />.8. Signature ~ QI lea s <br />.9. Prohibited Lands Statement <br />:laps 6 Exhibits <br />1. Legal description <br />2. Index map w ~'~ ` `" aek ~'" <br />3. Pre-mining 6 mining plan map <br />4. Plining plan - a) timetable <br /> <br />- b) depth 6 thickness of ore <br />~ <br />~ "- <br />P~ <br />body <br />