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7/78 • APPLICATION CHECKIL'I ST • III III III IIIIIII III <br />REGULAR 1 12 APPL I CAT ION NAME l vnnr. Co . ~~ekc~)O.,r., {~~~ F I LE #~ a~~ <br />COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br /> <br />2. Name of applicant <br /> I/ <br />3. Address E phone, local <br /> <br />4. Address E phone, general <br /> v <br />5. Person to contact <br />6. Parent Corporation, if any <br /> <br />7. Surface Owners <br /> <br />8. Mineral Owners / <br />9• Source of Legal Right-to-Enter I ~ <br />U ~ <br /> <br />10. Type of Mine/Substance <br />11. General Location 6 Elevation <br />12. County <br />.. <br /> ~ <br />13. Acreage <br /> L/ <br />14. Fee <br /> L- ~ <br />15• Present Land Use <br />/ .. <br />L <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature ~ <br />(over) <br />