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7/78 <br />~' <br />REGULAR 112 APPLICATION <br />ITEM <br />APPLICATION <br />CHECKLIST 1 III IIIIIIIIIIIIIIII <br />sss <br />NAME ~.IJI~ES/TE /(J wit FILE f{77-~y/ <br />COMPLETE (FILED) DATE S,F~'T ~_ /Si$'/ <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br />3. Address E phone, local <br />4. Address b phone, general <br />5. Person to contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners <br />$. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance <br />11. General Location b Elevation <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />l7. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />