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4/»__ ~ • ~ III IIINIIIIIIIIIIII <br />MINED LeVYD RECLAMATION <br />LIMITED IMPACT AND SPECIAL IO-DAY PERMIT APPLICATION CHECKLIST <br />File No. 77- 3'GName ~ap_..,( IQaS,c, =~,~.sdv Date of Filing (Completene:;s) <br />+~- <br />ITE.`S =~ COMPLETE ADEQUATE COMPIEidTS <br />Application Form <br />1. Name of operation <br />G/ <br />2. Name of applicant/operator L/ <br />3. Address S phone (local offices) <br />4. Address & phone (general offices) <br />5. Person to contact <br />6. Surface owners ~ I <br />7. iiiaeral owners <br />8. Type of mine/substance <br />9. General location ~ elevation ~ / <br />v <br />I0. County <br />11. Acreage <br />12. Fee <br />13. Present land use <br />14. Proposed future use <br />15. Signature <br />Maps and Exhibits <br />I. Exhibit A - Legal description ,/ <br />'" <br />2. Exhibit B - :Siring plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Sails infor- <br />mation , <br />~. Exhibit E - Reclamation plan <br />