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7/78 • APPLICATION CHECKLIST ~ III III III IIIIIII III <br />sss <br />LIMITED IMPACT (I10) _ NAME FILE H <br />SPECIAL 10-DAY (Ill) _ COMPLETE (FILED) DATE <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator ~ <br />3. Address ~ phone, local <br />V1.~c.J c,::c~rcss <br />4. Address b phone, general / ~- <br />5• Person to contact <br />6. Surface owners <br />7. Mineral owners <br />8. Source of legal right-to-enter <br />9. Type of mine/substance <br />10. General location E elevation <br />ll. County <br />12. Acreage <br />13. Fee <br />r1 ~+ti2 <br />14. Present land use <br />15• Proposed future use ~~ ~,~ <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />EXHIBIT B - Mining Plan ~"-`'1 ~"""~~ 1'~"'~ <br />EXHIBIT C - Map <br />EXH BIT D - Wildlife, Water Resources, <br />Vegetati n, Soils nformation f <br /> <br />