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4/77 ~ ~ III III III IIIIIIIIII <br />ML`rED LA.`rD RECLAMATION <br />LIMITED L*D?ACT AND SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br />File No. ~ 7-38-~Qame ~.l'pwP,v'S C'°'-~.^~~ate of Filing (Completeness) <br />,r <br />ITEM COMPLETE ADEQUATE COMPDI<ZTS <br />Application Form <br />1. Name of operation <br />'~' ~-~ f-w o Cap <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. iiineral owners ~' <br />8. Type of mine/substance <br />9. General location S elevation ~_ <br />10. County ~~ <br />11. Acreage ~' <br />12. Fee ~ ~(f-2f-c~~(r~ <br />13. Present land use <br />14. Proposed future use ~~ <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description tt <br />N ~~d <br />2. Exhibit B - :lining plan ~~ <br />3. Exhibit C - Map ~,v'~~ <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetatdon and Soils infor- <br />motion <br />Ar e,~J~ <br />I`~ <br />S. Exhibit E - Reclamation plan -/ ~~ <br />iP$~ <br />i~ <br />