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4/77 ~ • III'llllllllllllll~ <br />sss <br />MINED LA.~ID RECLAMATIOt7 <br />LIMITED IPiPACT AND SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br />File No. Qi• $rJ Name Iwvt~~{' ~,~'jA Date of Filing (Completeness) <br />ITEM COMPLETE ADEQUATE COMDSE:ITS <br />Application Form <br />1. Name of operation <br />~ L <br />I_+~1 PIi #o~ <br />2. Name of applicant/operator <br />3. Address b phone (local offices) ~/ <br />4. Address b phone (general offices) ~ <br />5. Person to contact v <br />6. Surface owners ./ <br />7. :iiaeral owners <br />8. Type of mine/substance J <br />9. General location 6 elevation J <br />10. County ~/ <br />11. Acreage - <br />~/ <br />12. Fee V ~ 5.~ <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. Exhibit B - ?fining plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Soils infor- <br />mation <br />y <br />5. Exhibit E - Reclamation plan <br />