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7/78 <br />LIMITED IMPACT (110) ~~~'~ <br />SPECIAL 10-DAY (111) _ <br />ITEM <br />APPLICATION CH EC<LIST ~./ <br />NAMES Z; ~ '/ ~` C~f~-~r~~ FILE z ~~ <br />COMPLETE (FILED) •DATE <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation ~~ <br />2. Name of applicant/operator <br />3• Address E phone, local <br />4. Address b phone, general / <br />5. Person to contact <br />\ <br />6. Surface owners ~\ <br />7. Mineral owners / <br />8. Source of legal right-to-enter <br />9. Type of mine/substance ~ <br />10, General location E elevation / <br />11. County ~ <br /> <br />12. Acreage ~ <br />13• Fee <br /> <br />14. Present land use <br /> <br />IS• Proposed future use• <br />16. Signature <br /> <br />Maps and Exhibits __ <br /> ~ <br />EXHIBIT A - Legal Description ~ <br />EXHIBIT 8 - Mining Plan ,f <br />EXH I B I T C - Map i„~ <br /> N~ <br />EXH IBIT D - Wi Idl ife'~Water Resources, <br /> <br />Vegetation, Soils Information ~ <br />