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- .. r <br />4/77 _ <br />III III IIIIII'~II'll ~ MLVED LAND RECLAPL4TIOP7 <br />sss <br />LIMITED I?[PACT AND SPECIAL IO-DAY PERI!IT APPLICATION CHECKLIST <br />(~. J L Uv.-C~.. <br />File No. T/ /Name /Vickvr-s M ~~Y~ D`~SDate of Filing (Completeness) <br />ITEM COMPLETE ADEQUATE COMMEiTfS <br />Application Form <br />1. Name of operation <br />2. Name of applicant/operator ~- <br />3. Address 6 phone (local offices) <br />4. Address & phone (general offices) <br />5. Person Co contact ~~ <br />6. Surface owners <br />7. 2iineral owners ~ <br />8. Type of mine/substance ~/~ <br />9. General location ~ elevation <br />10. County / <br />11. Acreage <br />12. Fee <br />13. Present land use l/~ <br />14. Froposed future use L/~ <br />15. Signature vi <br />Maps and Exhibits <br />1. Exhibit A - Legal description / <br />~/ <br />2. Exhibit~B - ~Sining plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Tdatez Resources, <br />Vegetation and Soils iafor- <br />motion / <br />!/// <br />5. Exhibit E - Reclamation plan <br />