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4/77 <br />iii iuiiiiiiiiu iii ,~ :~ <br />sss <br />MLYED LA.YD BECLAMATIO3I <br />LIMITED I2[PACT AND SPECIAL 10-DAY PERialT APPLICATIO.d CHECIQ,IST <br />File Vo.7~-ZSZ Name ~OO~tiSoN ~~~='~ ~ ~ ~ 'L~ Date of Filing (Completeness): <br />ITE:1 COMPLETE ADEQUATE CO.~cffETIS <br />Application Form <br />1. Name of operation <br />Z. ;`lame of applicant/operator / <br />3. Address 6 phone (local offices) <br />I c~ <br />~ <br />4. Address S phone (general offices) ~ ,~ <br />5. Pezson to contact <br />' <br />5. Surface oc~ners ~~ <br />I ~ <br />7. 2liaeral aaners <br />8. Type of mine/substance / <br />9. General location ~ elevation ! <br />I /~ i <br />L0. County / <br />11. Acreage <br />12. rFee <br />13. Present land use I ,~ <br />14. Proposed future use I <br />+ <br />i <br />15. Signature <br />:laps and E:chibits <br />L. Exhibit A -Legal description I <br />I <br />oK Ir~.c~Q <br />2. Exhibit B - ?fining plan ( / ~°°s''' '~ P' ,3 <br />3. :ciiibit C - uap I ~/ <br />4. Exhibit D - `dildlife, [dater Eesources, <br />7egetation and Soils iafor- <br />motion <br />5. Esfiibit E - 3eclamation plan , ~ .,.„~t~ y~ f;~., ;~ ~ <br />I s <~___ _. ,,._ . _ .., <br />