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7/78 ~lPPL l CAT I ON CHECKLIST ~ III IIIIIIIIIIIII III <br />__ REGULAR 112 APPLICATION NAME-H~!-~ ~¢-~x-l~-L'/'BILE !~ ?33-i~~ <br />COMPLETE (FILED) DATE ~ -'y - g 3 <br />ITEM <br />~_ COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />I. Name of operation <br />~` <br />2. Name of applicant <br />i <br />3. Address & phone, local ~ <br />4. Address 6 phone, general <br />5• Person to contact I <br />i <br />6. Parent Corporation, if any <br />7. Surface Owners ~ <br />I <br />8. 1lineral Owners <br />9. Source of Legal Right-to-Enter ~ <br />I ` <br />10. Type of Mine/Substance <br />Il. General Location E Elevation <br />12. County <br />I <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use ~ <br />18. Unpermitted Mining Operations 7 <br />0 <br />19. Affected Lands Z <br />n <br />20. Signature <br />(over] <br />