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7/7° ~ aP°LICAT!Otl C:icC:CL15T <br />. / NAME ~I l ( d~ ~"''~,.,-- C/~ er <br />LIMITED IMPACT (110) (~ <br />:PECfAL 10-DAY (I11) _ COMPLETE (FILED? DATE <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Aoolicaticn Form: <br />1. `Jame of operation <br />2. Yame of applicant/opera tar <br />3. Address 6 phone, ]ocal <br />w. Address 8 phone, general I f <br />5. Person to contact v ' I <br />6. Surface owners <br />7. Mineral owners <br />8. Source of legal right-to-enter <br />9. Type of mine/substance <br />10. General location 6 elevation <br />Il. Ccunty <br />f <br />12. Acreage <br />13. Fee <br />14. Present land use I <br />15• Proposed future use <br />i <br />16. Signature <br />Moos and Exhibits <br />EXH181T A - Legal Description / <br />,V/ _ <br />EXHIBIT B - Mining Pian <br />EXHIBIT C - Map <br />EXH IoIT D - 'ai ldl i fe, 'dater Resources, <br />Vegetation, Soils Information <br />F[LE c <br />