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]/78 APPLICATION CHECKL I ST III IIIIIIIIIIIII III ~~ - <br />• _ sss <br />REGULAR 112 APPLICATION NAME ~~•~~%=~ 5f;'.i ' -~i~%/`=_FILE # -~~~ <br />COMPLETE (FILED) DATE G' ~ '~ <br />A- ~ <br />ITEM ~"~ -- ~-~- i COMPLETE ADEQUATE COMMENTS <br />Application Form: <br /> <br />1. Name of operation ( <br />((( ~ <br />2. Name of applicant ~~. ~\ <br /> ~1 _ <br />3. Address 6 phone, local - I /~ <br />4. Address b phone, general <br />I <br />5. Person to contact <br />` <br /> ~ <br />6. Parent Corporation, i. any ~ <br /> <br />7. Surface Owners i <br />8. Mineral Owners ' ,~ <br />9. Source of Legal Right-to-Enter I I - <br /> <br />10. Type of Mine/Substance I <br />II. General Location E Elevation f I <br />~ ~ <br /> ~ <br />{ <br />12. County <br />13. Acreage ,' <br />14. Fee <br />15• Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use ~~ <br />I I <br />I _ <br />18. Unpermitted Mining Operations ~~ ~ <br /> \ <br />1 ' <br /> / <br />19. Affected Lands <br /> ~ <br /> <br />20. Signature ~ <br />(over) <br />