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j</78 7 ~ d ~ • APPLICATION CHECKLIST . III'lllll'I~IIII'll <br />/ ~ o sss <br />REGULAR 1 12 APPL I CAT ION NAME f /~ ~'`'~~~ ' ~U/f'~K/C Jj F I LE '~ ~>''/ 3 <br />COMPLETE (FILED) DATE /.~/~~~ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation ,c, F <br />2. Name of applicant ~ <br /> r i <br />3• Address z: phone, local I <br />4. Address E phone, general ~ - <br /> <br />5. Person to contact <br />k <br />r <br /> ~ <br />6. Parent Corporation, if any ~ ~ <br />' ~ <br /> r <br /> <br />7. Surface Owners i <br />, <br />8. `^.ineral Owners ~ <br /> 1^ <br />a, Source of Legal Right-to-Enter k~ ~ ~ ` <br />10. Type or Mine/Substance ~ ~ ~ <br />I1. General Location E Elevation ~ <br />I ~ <br />12. County I ~ I ~ <br />1?. Acreage I ~ <br /> <br />I / <br />14. Fee x '` <br />15• Present Land Use <br />. <br />( <br /> k - <br />16. Surrounding Land Uses <br /> x ~ <br />17. Proposed Future Use <br /> X ` <br />18. Unpermitted Mining Operations <br />19. Affected Lands ~ ,`/ <br />20. Signature ~ \ ~ <br />(over) <br />