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~ °: <br /> <br />-z- <br />3. Address and Phone Number <br />Local Offices <br />1 <br />G QDS ~n <br />4. Address and Phone Number of <br />General Offices <br /> <br />y3- <br />5. Name and Phone Number of Person <br />Staff Members Should Contact py~ d y ~ ~ ~ V~/DNE ti <br />6. Owner(s) of Record of Affected Land d ~Ct g.~ <br />(surface area) (If more than 2, list below) II -- <br />7. Owner(s) of Substance to be Mined <br />(If more than 2, list below) ~ ~ ~ a S <br />/a cep - - <br />8. Source of Legal Right-To-Enter <br />(Indicate what type of proof is <br />included in EXHIBIT G -lease, <br />deed, notarized letter, etc.) ~ ~ r <br />9. Type of Mine and Substance to be Mined Q <br />(Specify underground, open pit, <br />quarry, etc. & substance(s) to <br />be mined) VaY1r~ p,-,1dS,Db~ <br />10. (eneral Location and Elevation 1 ~,~ w~STyy~as~h~~~~~Ov~e <br />Miles & direction from nearest 1 ~l <br />town & approximate site elevation) 7 / 1 ~ ~ <br />~I.OVaIIDN Lj~a©D <br />11. County <br />~~ y- I -M ~ v <br />12. Acreage of Affected Lands <br />(Total surface acreage to be <br />included in permit) (~ a C r p S <br />13. Application Fee (See applicable~~~~~~,,,,~~,- ,~ <br />Rule to determine amount) ~I7 V " ~7 G.~ cJ ~ t 3~ <br /> <br />