Laserfiche WebLink
~.- -. <br />Limited Impact <br />Special 10-Day <br />~II II~~I~III~~~~ ~I~ <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />- Harelo( (ni~er <br />(110) Name" r RaM~,I, Gn al P; ~' File No.p1-8'S-/65 <br />(111) Complete Filed Date off-. 7,_,/ yfis <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> x x <br />2. Name of Applicant/Operator G x <br /> ~ <br />3. Address & Phone (Local) <br /> <br />4. Address & Phone (General) <br /> ~ X <br />5. Person to Contact <br />6. Surface Owners <br />7. Mineral Owners <br /> X <br />8. Source of Legal Right-To-Enter <br />9. Type of Mine/Substance <br /> x X <br />10. General Location & Elevation <br />11. county <br /> X <br />12. Acreage <br /> X <br />13. Fee. ~ <br />x <br />14. Present Land Use <br /> <br />15. Proposed Future Use <br /> <br />16. Signature <br /> x <br />