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ti <br />/j8 ,Zi~= ~ APPL Illllllllllllllllll n <br />LIMITED IMPACT (110) 1L g99 ~ ~ ~ r7E ' a. ~ FILE ,Y~/S <br />nMmC ~~ /IOU iL n <br />SPECIAL 10-DAY (I11)-- ----------------------COMPLETE-(FILED)-DATE ~ ~/ISt~/ 7 9------ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator / <br />` <br />/ <br />3. Address 6 phone, local / <br />4. Address ~ phone, general <br />~an~e S5. `36oU2 <br />5. Person to contact / ? ~~ z~F~~('a..~ ~(~-«.:S <br />6. Surface owners f <br />c^^--Q 6' `a L bov C <br /> <br />7. Mineral owners <br />~~.-,-¢ a3 rGo-.~ <br />8. Source of legal right-to-enter L/ <br />9. Type of mine/substance L/ <br />10. General location b elevation <br />11. County v <br />12. Acreage <br /> v <br />13. Fee !/ /1~ '~~ ~( Z ~( <br />14. Present land use ~ <br />15• Proposed future use ~1 k'~~ <br />S <br /> 7 <br />16. Signature: <br />Maps and Exhibits <br />EXHIBIT A - legal Descripri on , / <br />!~ n <br />C~^~~ ~ (tip: /~2n~J ~e <br />EXHIBIT B - Nlining Plan <br />EXHIBIT C - Map '/ 2 ~~ (~ ~ R `~ <br />C ~ '~~ <br /> Y -- a <br />~--- <br />EXH IBIT D - Wildlife, Water Resources, 7 <br />Vegetation, Soils Information '~p~~~ 2 <br />