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4/77 ~ . III'IIIIIIIIIIII II~ <br />sss <br />MIVED LeV`ID RECLAMATION <br />LIMITED IPD?ACT Fu~ID SPECIAL 10-DAY PERMIT APPLICATION C9ECKLIST <br />File No.',P7- ~~ Name ([arFQocl~ /~e,~; Date of Filing (Completeness) <br />ZTEPf COMPLETE ADEQUATE COMME:ZTS <br />Application Form <br />1. Name of operation 1/ <br />" <br />2. Name of applicant/operator <br />3. Address b phone {local offices) / /~ <br />!/ f <br />4. Address 5 phone (general offices) <br />5. Person to contact //~ <br />6. Surface owners I / <br />7. :iiaeral owners v / <br />8. Type of mine/substance ~~ ~/ <br />9. General location S elevation yi <br />10. County ~/ <br />11. Acreage ~. ~~' <br />12. Fee /7~ / C ~ ^ ' 7 r ~ ~. r_ <br /> <br />13. Present land use <br />~ i <br />14. Proposed future use ~ ~ <br />15. Signature / <br />Maps and Exhibits <br />1. Exhibit A - Legal description ~ <br />2. Exhibit B - ~Sining plan "~ ~~ <br />.et .- <br />3. Exhibit C - Map ~~ <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation aad Soils infor- <br />mation ~~ `~"" ' '"` <br /> <br />5. Exhibit E - Reclamation plan sec ~Ny.,~pc c! <br />q '^~ "~~~ <br />