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III III III IIIIIII III 10) ~ • APPLICATION CH ECKL/ ST~~~~~ ~~~t y <br />ggg _ NAME ~<% ~_ F I LE f! /tS / <br />SPECIAL 10-DAY (111) _ COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: z ~ <br /> <br />1. Name of operation / <br /> <br />/ <br /> <br />/ <br />2. Name of applicant/operator <br /> <br />3. Address b phone, local / ' <br />4. Address & phone, general , / <br />5. Person to contact / <br />6. Surface owners <br />7. Mineral owners <br />8. Source of legal right-to-enter <br />9• Type of mine/substance / <br />10. General location E elevation <br /> l <br />11. County / <br />12. Acreage ~ ~i <br />13. Fee L/ ~O ~~ t/Q~,~~ $/O. <br />14. Present land use <br />15. Proposed future use <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - L <br />l D <br />i <br />i <br />ega <br />escr <br />pt <br />on <br />EXHIBIT B - Mining Plan / <br />EXHIBIT C - Map V <br /> <br />~~ <br />EXH IBIT D - WildliYe, Water Resources, J ~~ , <br /> <br />VegetaY~on, So' s Information - <br /> <br />