REV14309

• Permit No: M1983084
• IBM Index Class Name: Revision
• Doc Date: 7/8/1989
• Doc Name: REGULAR 112 PERMIT APPLICATION FORM
• Type & Sequence: SO1
• Media Type: D
• Archive: No

_2_
10.
Individual's Name:
Company Name:
Street:
City:
State:
Area Code:
Zip Code:
Area Code: ~/ ~ Telephone: ~~(~ • ~~~ `
INSPECTION CONTACT (if different from applicant/operator above)
Company Name:
Street:
City:
State:
Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name:
Company Name:
Street:
City:
State:
Area Code: ~/9 Telephone: ,Q3/o -a,Ol~~
PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name: ~~~~ ~, p~i~w,.~,~e
Zip Code:
Telephone:
11. Primary future Cropland(CR) Pastureland(PL) General Agriculture(GA)
land use - Rangeland(RL) - Forestry(FR) - Wildlife Habitat(WL)
(check one): - Residential(RS) - Recreation(RC) - Industrial/Commercial(IC)
_ Developed Water l~sources(WR) _ Solid Waste Disposal(WO)
12. Primary present Cropland(CR)
Pastureland(PL) General Agriculture(GA)
land use _
_
_
Rangeland(RL)
Forestry(FR) Wildlife Habitat(WL)
(check one): _
- Residential(RS) Recreation(RC) - Industrial/Commercial(IC)
Developed Water l~sources(WR)
To the best of my knowledge, all the information presented on this application form and
the attached Exhibits A-P are true and correct (must be signed by
a
p~plicant/operator).
Dat e: z~ 3 -fig By:~~~f.(/4. ~/
/
L"I~ialO.t - ~C~/L)