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7/78 APPLICATION CHECKLIST <br />~r-ti D~IFd P,'f <br />REGULAR 112 APPLICATION <br />COMPLETE (FILED) DATE <br />?9- <br />FILE 1/ ~ <br /> <br />ITEM <br />COMPLETE ADEQUATE COMMEPITS <br />Application Form: <br />1. Name of operation <br />~ <br />2. Name of applicant <br />3. Address E phone, local l <br />/ I <br />4. Address ~ phone, general <br />5. Person to contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners ~~ <br />9• Source of Legal Right-to-Enter ~ I <br />10. Type of Mine/Substance <br />11. General Location E Elevation <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses f <br />17. Proposed Future Use <br />t~ <br />18. Unpermitted Mining Operations / <br />! <br />/ <br />19. Affected Lands / <br />ZO. Signature / <br />(over) <br />