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7/78 APPLICATION CHECKLIST <br />REGULAR 112 APPLICAT• NAME Jy C~ (~ FILE N $0-~,~/J <br />i <br />COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />/ <br />2. Name of applicant <br />3• Address b phone, local ~ r <br />4. Address E phone, general <br />5. Person to contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners <br />9• Source of Legal Right-to-Enter ~ ~~ ~ a' <br />10. Type of Mine/Substance <br />t/ <br />11. General Location E Elevation / <br />12. County <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 />v <br />20. Signature ~" <br />v' <br />(over) <br />