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7/78 APPLICATION CHECKLIST <br />• • <br />REGULAR 112 APPLICATION III'IIIIIIII'IIIIII ~o-u-d~ .~-_~.., !r+_a-C //FILE N75-/9S <br />sss ETE (FILED) DATE O 3/. ~5~7%' <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant ~ <br />3. Address b phone, local ~ <br />4. Address & phone, general ~~ <br />5. Person to contact I `~ <br />I <br />6. Parent Corporation, if any ~ ~ <br />7. Surface Owners <br />v <br />8. Mineral Owners t~ <br />9. Source of Legal Right-to-Enter ~~ <br />10. Type of Mine/Substance <br />11. General Location b Elevation <br />12. County <br />13. Acreage <br />14. Fee ~~ <br />15. Present Land Use <br />16. Surrounding Land Uses <br />`~ <br />17. Proposed Future Use ~ <br />18. Unpermitted Mining Operations ~~ <br />19. Affected Lands v <br />20. Signature ~/ <br />(over) <br />