PERMFILE55598

• Permit No: M1984069
• IBM Index Class Name: Permit File
• Doc Date: 4/23/1984
• Doc Name: APPLICATION WORKSHEET CHECKLIST
• Media Type: D
• Archive: No

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MINED LANt~ RECLAPIATION
Application Worksheet/Checklist
Limited Im act 110 Natne 4S~~.tZ c~.`t,~etd•
P ( ) tip, Iz t ~t~. P+ File No./~1-8'+~-d 69
Special 10-Day (111) Complete Filed) Oate /}fir;( a?~ igFy
ITEM COMPLETE ADEQUATE COMMENTS
Application Form:
1. Name of Operation
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2. Name of Applicant/Operator , / /
3. Address & Phone (Local) ~ J
4. Address & Phone (General} / /
5. Person to Contact
6. Surface Owners `!
7. idineral Owners ~ V
8. Source of Legal Right-To-Enter / /
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g. Type of Mine/Substance ~ . /
V
10. General Location & Elevation / _ /
V
l1. County / 1/
V
12. Acreage /
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13. Fee ~ ~ ~
14. Present Land Use /
15. Proposed Future Use .e e S a 5 P`e S `z 5 P~
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16. Signature / /
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