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y ~' -~. • • II I I I I I I I I II I III III <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist n <br />Regular 112 Application Name Gwe~,,'~ I ~,d-(, ~aJ~ File No. 8~'~S9 <br />Complete Filed Date [O~~;f'7 <br />ITEM 7 ~ 9 b ~~ ~~ h ~ U ~ ( I Z ~r~COMPLETE ADEQUATE COMMENTS <br />Application Form: 77CiOJJ ~1'DM <br />1. Name of Operation <br />/ <br />2. Name of Applicant/Operator / <br />3. Address & Phone (Local) <br />4. Address & Phone (General) ~ <br />5. Person to Contact <br />6. Parent Corporation, if any ~ <br />7. Surface Owners ~ <br />8. Mineral Owners <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Substance / <br />11. General Location & Elevation <br />12. County <br />13. Acreage <br />9.9b <br />14. Fee ~/~ <br />15. Present Land Use / ~ ~ <br />16. Surrounding Land Uses / ~ / <br />1 <br />W <br />17. Proposed Future Use / {~ <br />G <br />