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]/]8 ~ APPLICATIO`! CHcC;CLIST <br />LIMITED IMPACT (110) X NAME y,~~ Sol~e~~ F[LE ~__ <br />SPECIAL 10-OAY (111) _ COMPLETE (FILED) DATE <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Aoolication Form: <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address r; phone, local <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 8 elevation ~~ <br />_~ <br />11. County t/ <br />12. Acreage <br />13• Fee ~ <br />14. Present land use <br />15• Proposed future use <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description / <br />C/ _ <br />EXHIBIT 8 - Mining Plan <br />EXHIBIT C - Map <br /> <br /> <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information <br />~~ 1 <br />{~C.Jy Ub ~1.,.•ed <br />1v1 <br />