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,,_., <br />/~~ <br />\ III IIIIIIIilllll 111 <br /> 999 <br />*SI;dED Lel\~ EECL.~*L~TION <br />LI,fITED I'LpACT AND SPECI~I. 10-DAZ PEPIdIT APPLICATION C::EC!CLIST_ <br />rile No. ? ; ~ "~ ;Name !~ <br />Date of Filing (Completeness): <br />ITE.? I COAfPLETE ADEQUATE COt~ItiE:dTS <br />Application Form <br />I. Game of operation >i •% ~ <br />2. Name of applicant/operator <br /> <br />3. Address & phone (local offices) i <br />-~ <br /> ~ ~ <br />4. Address & phone (general offices) I .~ <br />5. Person to contact 1~ ~ <br />5. Surface ocmers ,; I ~' <br /> ~ <br />7. iLineral owners v <br />i <br /> / if` ~'au <br />S. Type of nine/substance I <br />9. General location ~ elevation ~~ ~ <br />I <br />10. Count) ~ J L• <br />11. Acreage ~ ~ I <br />12. Fee ~ ~ I ~ <br />13. Present lard use ~ -' <br /> I i <br />14. Froposed fu[ure use ' <br />I5. Signature '; ~ I / <br /> <br />Maps and Exhibits <br />' /• ,' •/ <br />1. E:chibit A - Legal descriation I f/ ~ <br />, <br />2. E::hibit 3 - .fining plan ~ '. ~ ~ <br /> ~ ' <br />3. E::hibit C - :~fao ~/ <br />4. Exhibit D - Wildlife, Water Sesources, ! <br /> <br />Vegetatdon and Soils infor- <br />~ / _ <br />I ~ <br />I <br />oration I J <br />3. Exhibit E - P.eclamation elan ~ (~~ <br />