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7/78 ~ •~P III IIIIIIIIIIIIIIII r <br />REGULAR 1 12 APPL I CAT 10N NAME ~z~- ./-- -~ --- ~~,1 LE N 7Y `/ <br />COMPLETE (FILED) DATE~„_, ~ i yg z <br />ITEM <br />COMPLETE ADEQUATE CG MMEVTS <br />Application Form: <br />1. Name of operation <br />Ci <br />2. Name of applicant ~ <br />3. Address b phone, local ~ <br />4. Address E phone, general <br />~ ~ <br />5. Person to contact ~-~ <br />~ I <br />6. Parent Corporation, if any <br />", ~ <br />7. Surface Owners ~- <br />8. Mineral Owners ~- <br />9. Source of Legal Right-to-Enter I <br />i <br />10. Type of Mine/Substance r ' <br />Il. General Location E Elevation i <br />12. County / <br />13. Acreage - <br />14. Fee ~~ <br />15• Present Land Use ~ <br />16. Surrounding Land Uses <br />~, <br />17. Proposed Future Use <br />l/ <br />18. Unpermitted Mining Operations ~/ <br />19. Affected Lands <br />20. Signature L% <br />(over) <br />