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7/78 APPLICATION CHECKLIST <br />LIMITED IMPACT (110) ~ `-' NAME ~~ ~~ ~'`'"--~~~'' Ci4~~' FILE N ~w <br />SPECIAL 10-DAY (1 1 1) _ COMPLETE (F 1 LEU) DATE i` ~~ '~ - % - •- ,~ <br />---------------------------------------------------------------------------------------------- <br />ITEM S y ~~ ._. Jf r ~ ^ ~~ _ COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator i <br />3. Address b phone, local <br /> <br />4. Address & phone, general <br />5. Person to contact / <br />/ <br /> <br />6. Surface owners ~ <br />7. Mineral owners <br />8. Source of legal right-to-enter <br /> ~ ~ <br />9. Type of mine/substance <br />10. General location 6 elevation <br /> <br />11. County <br />12. Acreage <br />13. Fee '~ <br /> <br />14. Present land use <br />15. Proposed future use <br />16. Signature / <br />Maos and Exhibits <br />EXHIBIT A - Legal Description % ' i <br />EXHIBIT B - Mining Plan / i~ <br />EXHIBIT L - Map ~ i <br /> . . . <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information <br /> <br />