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7/78 <br />REGULAR 112 APPLICATION <br />IIIIIIIIIII ~ <br />,~ <br />NAME~~ - "Lar~~~ k/e,r psi-`FILE [~ -~3 <br />COMPLETE (FILED) DATE V une a 9 / 9~'/ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />~ <br />`/ <br />/ <br />~ <br />2. Name of applicant ~ ~ <br />3. Address E phone, local ~ x <br />4. Address 6 phone, general <br />~~ <br />5. Person to contact <br />6. Parent Corporation, if any <br />7. Surface Owners ~, <br />8. Mineral Owners ~ I <br />9. Source of Legal Right-to-Enter I <br />jC <br />10. Type of Mine/Substance <br />Il. General Location E Elevation x <br />IZ. County <br />13• Acreage <br />14. Fee <br />15. Present Land Use 1~ <br />16. Surrounding Land Uses <br />17. Proposed Future Use ~~,~ /,I ~; F~ <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br /> <br />• APPLI( III IIII <br />(over) <br />