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~ti/77^ <br />C~u ~~~1 <br />?•fIAED L?uYD RECLAM.4TIOtI • <br />LIMITED LnlPACT A~yD S?ECZ9L IO-DAY P~2ialT A'cPLICATIO:I C3ECEZIST <br />File Vo.~~"ZZZ Yaae /CliiyL~.clcy, ~'LtiG Date of Filing (Completeness): /"~3~ 7~ <br />ITE<`i COMPLETE I AiEQIIATE CC~i.`SE:TTS <br />Application Form <br />1. CTame of operation <br />2, name of apalicaat/operator <br />3. Address S phone (local offices) <br />4. Address & phone (general offices) <br />5. Person to coacact / t <br />r <br />5. Surface oiaaers I ) <br />I <br />7. 2iineral owners • / I <br />! <br />III <br />8. Tape of nine/substance ~ / I <br />9. General location 5 elavation I <br />I0. Cauaty <br /> I ~ <br />I1. acreage p <br />I2. Fee ~ ~ ~ ~ 7_~ - -- . , <br />13. Present land use / ~ <br />IS. Proposed fut•,se use ~ ~ <br />i <br />I5. Signature / <br /> ~. <br />."a9s and Exhibits <br /> ' <br />1. Exhibit A -Legal description `~ <br />Z.. Exhibit 3 - 3ai.ag plan ,~ (~- I <br />3. =ambit C - :•ap ~/ , C~ {- <br />~. ca.4ibit D - ' dlif,., date Resources, <br />r ~ <br />~ I <br />J ~ '- -- I __ __ <br />- <br />"-" <br />leg oa <br />d Soils iafb - V I <br />nation + ` <br />I _ <br />I <br /> <br />5. E~.'~ibit ? - Reciatation plan <br />`/ .~' - I _ 7 <br />