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<br />-2- <br />3. Address and Phone Number of - <br />Local Offices n ~p <br />4. Address and Phone Number of <br />General Offices <br />S~ ~ ~ <br />5. Name and Phone Number of Person <br />Staff Members Should Contact _ <br />6. ner(s} of Record of Affected Land <br />(surface area) (If more than 2, list below) °Q/ ~o S S <br />.~~v, <br />7. Owner(s) of Substance to be Mined <br />If more than 2, list below) ~~a(ll~a Lj oS~ <br />8. Source of Legal Right-To-Enter <br />(Indicate what type of proof is <br />included in EXHIBIT G -lease, <br />deed, notarized letter, etc.) <br />9. Type of Mine and Substance to be Mined <br />(Specify underground, open pit, <br />quarry, etc. & substance(s) to <br />be mined) <br />D~ <br />a <br />~e~ <br />10. Generai Location and Elevation <br />(Miles & direction from nearest <br />town & approximate site a//levation) P ~ <br />to Y]7 .~~G.S'. mac: ~~h O i~ G~//G C. ~~ ~di G/00 <br />11. County _ , <br />12. Acreage of Affected Lands <br />(Total surface acreage to be <br />included in per~ait) <br />13. Application Fee (See applicable <br />Rule to determine amount) .,~ c ° <br />~~~ <br />