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7/78 • ~ APPLICATION CHECKLIST ~ ~) III IIIIIIIIIIIII III <br />REGULAR 112 APPLICATION <br />NAME ~,s0~ ~~ FIL'c~ ~3'~yZ <br />COMPLETE (FILED) DATE ~~ LS. / 9 g ~__ <br />-----------------------------------------------------------------f'---- ------ ------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />I. Name of operation <br />2. Name of applicant <br />3. Address 6 phone, local <br />4. Address 6 phone, general <br />5. Person to contact <br />I <br />6. Parent Corporation, if any <br /> <br />7. Surface Owners i <br />8. Mineral Owners ~ <br />9. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance <br />11. General Location E Elevation <br /> <br />12. County I <br />13• Acreage <br />14. Fee <br />15• Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />