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~,~$ <br />L1riITED IMPACT (110) <br />SPECIAL 10-DAY (ill) <br />ITc-M <br />APPLII:ATID:1 C~i:C:<L15T 1111 IIIIIIIIIIIIIIII ~,_ <br />- NAME ~~i~C~9nd M~GrsPC61:i~? FILE r~ <br />CD~`1PL~, E (FILED) D ~E f <br />COMPLETE <br />ADEQUATE COMMENTS <br />Aoolication Form: I <br />1. Name of operation ~ I - <br />2. Nar..e of applicant/operator ~ ~~ <br />3. Address b phor.¢, local / <br />4. Address b phone, general ~ I I <br />5. Person to contact ,~ <br />5. Surface owners <br />l <br />7. Mineral owners <br />I <br />8. Source of legal right-to-enter ~ <br />4 <br />9. Type of mine/substance <br />10. General location b elevation <br />il. County / I <br />V <br />12. Acreage / / <br />l I <br />i <br /> <br />13. Fee <br />/ ~ <br />I _ <br />14. ?resent land use <br />15. Proposed future use ~ ~ I <br />I <br />16. `;nature I <br />Moos and Exhibits <br />EXHIBIT A - Legal Description <br />~~ _ _ <br />EXHIBIT B - Mining Pian ~ <br />EXHIBIT C - Map <br />EXH uIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information <br />r <br />