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7/7B <br /> <br />LIMITED IMPACT (110) ~ <br />)~~ <br />ITEM <br />~ II I III I II I II IIII III :CKL I ST ~~_ <br />sss NAME ~U2h~/ SOU S` /r/ F I LE H ~~ <br />COMPLETE (FILED) DATE <br />---------------------------------------------------------------- <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />~~ <br />' <br />2. Name of applicant/operator v ~. <br />3. Address /; phone, local <br />C~ / <br />4. Address E phone, general ~_ <br />1 <br />5. Person to contact (~ I <br />/ <br />6, Surface owners v. ( <br />/ <br />7. Mineral owners ~/ ~ <br />8, Source of legal right-to-enter <br />9. Type of mine/substance ~ <br />10, General location 6 elevation <br />11. County ~' \ <br />1 <br />12. Acreage <br />C~ I <br />/ ~ ~ <br />l3. Fee ~ / <br />T~~~/ - <br />'~7~c7~1~- ~~ oK. <br />14, Present land use ~ /' <br />15• Proposed future use v- <br />16. Signature ~ _ C <br />\ <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />~ L ~ <br />~' ~ ' ~ ~ % +`" / -.' c,C <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map ~~ (c~ ~ Ti <br />~ ~ Fi i /, ,:/NG ':. <br />L~~_,,,, ~,. <br />EXH IBIT D - Wildlife W xer Resources, <br />Vegetation,, Soils Information's II ~ <br />{'~- <br />i ~~L °' <br /> <br />