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7/78 • <br />LIMITED IMPACT (110) ~- <br />APPLICATION CHECKLIST <br />NAME ~ ~~{-~-' =~-~ F I LE I) 8o job <br />SPECIAL I O-DAY ( III ) _ COMPLETE (FILED) DATE S ,~~• 30 , 19f1o <br />---------------------------------------------------------------------- --T <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address & phone, local <br />J <br />4. Address t; phone, general ~~ <br />5. Person to contact -~~ <br />6. Surface owners C/~ ~ <br />7. Mineral owners <br />~i- <br />- <br />8. Source of legal right-to-enter ~ <br />9. Type of mine/substance ~/ <br />10. General location & elevation ~_ <br />11. County <br />12. Acreage ~~ <br />13. Fee ~ <br />14. Present land use <br />15• Proposed future use <br />16. Signature <br />~_i <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />(~ <br />EXHIBIT B - Mining Plan /~~ I <br />EXHIBIT C - Map L~ <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information ~_ <br />