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~/~8 <br />LIMITED IMPACT (110) <br />SPECIAL 10-DAY (111) <br />ITEM <br />APPLICATIO"J Ci~IECiCLIST <br />~ /fi/~Sle~ F',tii~ <br />NAME ~A' 1c ~r~ :~r <br />FILE a <br />COMPLETE (FILE U) DATE i <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address E phone, local f <br />' <br />4. Address E phone, general <br />5. Person to contact <br />6. Surface owners v i <br />7. Mineral owners ,~ <br />8. Source of legal right-to-enter v <br />9. Type of mine/substance <br />10. General location b eleaation <br />11. County ~~ <br />12. Acreage <br />13• Fee <br />~~ <br />14. Present land use <br />15. Proposed future use <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description ___.- <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map <br />~/ <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information FJ-y,,cc... <br />~ <br />