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4177} ~ iIIIIIIIIIfflllllll <br />~ifP1i ED L~~ID RECLAZL4TIOiI <br />LIMITED L*IPACT AND SPECIAL 10-DAY PERialT APPLICATION CHECKLIST <br />~~27 Crufdu,~u ,,. ~uve~ ~~ <br />File Va. ~ L Name Cr ~ , (,~ I d Co„µd.~_ Date of Filing (Completeness) <br />ITE.*i COt~LETE ADEQUATE COPAfEdTS <br />Application Form <br />1. Name of operation <br />2. name of applicant/operator <br />3. Address S phone (local offices) <br />4. Address & phone (general offices) <br />5. Person to contact <br />5. Surface o~,mers f <br />7. Piiaeral owners i <br />i <br />8. Type of mine/substance <br />9. General location & elevation j <br />I <br />10. County <br />11. Acreage <br />12. Fee <br />13. Pzesent land use ,~ <br />14. Proposed future use ~ <br />I <br />.. <br />15. Signature 7 1 <br />:*aps and Exhibits <br />1. E.ehibit A - Legal description <br />2. Ex'~ibit 3 - ??fining plan <br />3. Exhibit C - :"ap X <br />4. Exhibit D - 'di~dlife, Water Resources, <br />57e etatioa and Soils inror- <br />maC~Ga .. .. <br /> <br />i I ~ b 7~ <br />„0 - n,j~ p ,~ , <br />4 <br />~ ' <br />5. E.-chibit E - „eclamation plan I ~ ~ <br />