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4/77' • <br />• <br />MINED LPu~ID RECLAMATIOtd <br />p ~~--22LIMITED ItIPACT/~,A,iW~ ~S,P~ECIAL 1C-UAY PERialT APPLICATION CHECKLIST <br />~e Na. 70'rTJ Name ~1d11~ I,OUJUIiy-' Date of Filing (Completeness) <br />ITEM CO~LETE ADEQUATE COMPfEdTS <br />Application Form <br />1. Name of operation <br />` l <br />V <br />rn . <br />2. Name of applicant/operator / <br />V <br />3. Address fi phone (local offices) <br />4. Address fi phone (general offices) <br />5. Person to contact <br />fi. Surface owners J <br />7. tfiaeral owners <br />8. Type of mine/substance v <br />9. General location fi elevation <br />10. County \/ <br />II. Acreage <br />12. Fee <br />13. Present land use <br />14. Proposed Future use <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />2. Ex'~ibit B - 4Siaing plan <br />3.' Exhibit C - Map <br />4. Exhibit D - Wildlife, [dater Resources, <br />' Vegetation and Soils infor- <br />mation <br />5. Exhibit E - Reclamation plan <br />r <br />i <br />1C <br />