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4/77 <br />~I I I II I I~ ~ I~ ~I~~ ~~~ ` <br />MIMED LAND RECLAMATIOt7 <br />-.-- - <br />r <br />LIMITED IPiPACT AidD SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST / <br />File No. 77-~6 Name L~c~ ~ Date of Filing (Completeness): 7 ALT <br />IT_&'3 COMPLETE ADEQUATE COMMEiTTS <br />Application Form <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address 6 phone (local offices) / <br />4. Address & phone (general offices) / <br />5. Person to contact <br />6. Surface owners ~ ~ <br />7. Pfineral owners <br />B. Type of mine/substance <br />9. General location ~ elevation <br />10. County <br />11. Acreage <br />12. Fee ,/ <br />13. Present land use <br />14. Proposed future use / <br />15. Signature ,~ <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />~/ <br />2. Exhibit B - :fining plan f <br />3. Exhibit C - Map ~ <br />4. Exhibit D - Wildlif~'Water~sources, <br />Vegetationand SoilsiYnfor- <br />mation <br />/ <br />/ <br />5. Exhibit E - Reclamation plan / <br />