PERMFILE42652

• Permit No: M1979191
• IBM Index Class Name: Permit File
• Doc Name: APPLICATION CHECKLIST
• Media Type: D
• Archive: No

]/]$ III III III IIIIIII III ~ APPLICATION CHECKL I ST
REGULAR 112 APPLICATION NAME Tl..a ~k...~L '~'~11s ~~~-~ FILE .# 74'~`~ l
COMPLETE~(FILED) DATE
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ITEM
COMPLETE ADEQUATE COMMENTS
Application Form:
1. Name of operation
(/
2. Name of applicant L/
3. Address E phone, local ~/
4. Address 6 phone, general
5. Person to contact G~
6. Parent Corporation, if any ~-
7. Surface Owners ~/
$. Mineral Owners L/-
9• Source of Legal Right-to-Enter /
!/ I '
10. Type of Mine/Substance ~'
11. General Location & Elevation G~
12. County
13• Acreage

14. Fee ~-
//
15• Present land Use
16. Surrounding Land Uses ~/
17. Proposed Future Use
1$. Unpermitted Mining Operations
19. Affected Lands ~~
20. Signature `
(over)