PERMFILE62886

• Permit No: M1995021
• IBM Index Class Name: Permit File
• Doc Date: 3/17/1995
• Doc Name: APPLICATION FORM
• Media Type: D
• Archive: No

a
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name: "
Company Name
Street:
City:
State: Zip Code:
Area Code: Telephone:
INSPECTION CONTACT'
Individual's Name:
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
CC: STATB OR FIiDSRAL LANDOWNHR (if anv)
Agency:
Street:
City:
State: Zip Code:
Area Code: Telephone:
CC :~ STATB OR FEDERAL I,AT7DOWN1iR (if anv)
Agency:
Street:
City:
State: Zip Code:
Area Code: Telephone:
11. Primary future (Poet-mining) land use (check one):
Crapland(CR) _ Pastureland(PL) _ General Agriculture(GA)
~ Rangeland (RI,) _ ForestrY(FR) _ Wildlife Habitat (WL)
Reaidential(RS) Recreation(RC) Industrial'/CCa®ercial(IC)
_ Developed Water Resources (WR) = Solid Waste Disposal (WD)
12. Primary resent land use (check one):
Czapland(CR) _ Paetureland(PL) _ General Agriculture(GA)
-_X Ran~eland(RL) _ Forestrx (PR) _ Wildlife Habitat (WL)
Resideatial(RS) Recreatioa(RC) Industrial/Coa®ercial(IC)
_ Developed Water Reeources(WR) _ Mining(MN)
13. If this operation will use designated chemicals, or will result, or presently has
acid mine drainage - you cannot use this application form. You must submit a either
a 110d or 112d application form~for Designated Miaiag Operations. Ia either case,
you must list any acidic or toxic-forming materials, exposed or disturbed ae a
result of the mining operation, and whether the operation will result_in or
presently has acid mine drainage:
Descrintion of Conversion:
]f you are converting an existing operation, provide a brief narrative describing the
proposed change(s).
Mane 6 8xhibits:
Subout two (2) complete, unbound copies of the following application exhibits:
6.3.1 sxHIBIT A - Legal Description and Location Map
6.3.2 IDQiIBIT H - Site Description
6.3.3 HXFiIHTT C - Mining Plan
6.3.4 HRFiIHTT D - Reclamation Plan
6.3.5 BXHIHIT S - Mape
6.3.6 SXEiIBIT F - Liet of Other Permits sad Licenses Required
Title: