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7/78 ~ APPLICATION CHECKLIST <br />REGULAR 112 ARRLICATION NAME ~ ~ ~' D FILE k ~~ ~~ <br />COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM ~~~ ~- ~~ ~ ~ / ~ ~ COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />/ <br />~ <br />2. Name of applicant l <br />\ <br />3• Address & phone, local I ~ <br />4. Address E phone, general \ I <br />1 / <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 / l <br />10. Type of Mine/Substance ~ i / <br />11. General Location E Elevation ) <br />r ~~ <br />12. County / <br />l <br />13. Acreage \ <br />) <br />14. Fee ~,: i ~ / i ~'- C <br />15. Present Land Use / <br />( / <br />16. Surrounding Land Uses I~ <br />i <br />17. Proposed Future Use <br />( <br />18. Unpermitted Mining Operations \ <br />19. Affected Lands ~ <br />20. Signature 1 <br />1 <br />~ Ll-'~ <br /> <br /> <br />(over) <br />