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7/78 <br />REGULAR 112 APPLICATION <br />APPLICATION CHECKLIST ~~ III'll'll'll"II'II1~ <br />NAME /~ S ~, ; ~ - __~ <br />COMPLETE (FILED) DATE Nnv. a 7, t `! 7 9 <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />x <br />2. Name of applicant ~ i <br />3. Address E phone, local x <br />4. Address E phone, general x <br />5. Person to contact <br />6. Parent Corporation, if any / <br />n <br />~ <br />7. Surface Owners " <br />8. Mineral Owners X <br />9. Source of Legal Right-to-Enter x <br />10. Type of Mine/Substance k X <br />Il. General Location b Elevation <br />12. County x ,~ <br />13• Acreage <br />X <br />X. <br />14. Fee <br />15. Present Land Use x <br />16. Surrounding Land Uses <br />x <br />y <br />_ <br />17. Proposed Future Use x ~ <br />i <br />18. Unpermitted Mining Operations ~ ~ <br />/'~~ <br />19. Affected Lands >` <br />20. Signature _ <br /> <br />(over) <br />