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4/77 'll'~I'I"I~1"'Il' • <br />MI`IED LAND RECLAMATIOi7 <br />LIMITED IPtPACT AND SPECIAL 10-DAY PERMIT APPLICATION C.°.ECKLIST <br />File No.77-Z5Z Name u}~t/YIII~ UGG ( ~/r Date of Filing (Completeness) :. <br />ITE:1 CO'~LETE ADEQUATE COMMEiTfS <br />Application Form <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address S phone (local. offices) / <br />V <br />4. Address & phone (general offices) / <br />5. Person to contact <br />6. Surface owners <br />7. Diiaeral owners <br />8, Type of mine/substance / <br />9. General location ~ elevation <br />10, County <br />11. Acreage / <br />12, Fee UIU~ ~ <br />13. Present land use <br />14. Proposed future use <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />~ <br />2. Exhibit B - :Siniag plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife; Slater Resources,` <br />Vegetation and Soils infor <br />oration <br />5. Exhibit E - Reclamation plan <br />