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7/78 APPLICATION CHECKLIST <br />REI;ULAR 112 APPLICATION NAME FILE ~ 7 -~ I! <br />_ _________________________________________COMPLETE_(FILED)_DATE_F'l4rvA ~ 1 91? ~ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />~~lication Form: <br />1. Name of operation <br />2. Name of applicant <br />3. Address E phone, local <br />4. Address & phone, general <br />5. Person to contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners ~ <br />9. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance <br />11. General Location & Elevation <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />