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]/]$ APPLICATION CHECKLIST <br />~- -- - ~ <br />a FILE /t 79-.~•; <br />LIMITED IMPACT (I10) ~„ IIIIIIIIIIIIII'lllll <br />' <br />COMPLETE (FILED DATE <br />~p . <br />SPECIAL 10-DAY (IIl) _ 999 /~"}/y,Q'o <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation x <br />2. Name of applicant/operator <br />3. Address & phone, local <br />4. Address E phone, general <br /> <br />5. Person to contact <br />6. Surface owners <br />7. Mineral owners x <br />8. Source of legal right-to-enter `~ <br />J <br />~ <br />Type of mine/substance " <br />J~ <br />10. General location & elevation <br />11. County x <br />12. Acreage <br />1 Fee <br /> <br />C; frs~ J/ <br />~ <br />, <br /> ter 2~r <br />14. Present land use Y <br />/ ~ c~ <br />IS• Proposed future use <br />16. Signature ~ hp~o( T%j="~f~"mss` <br />Maps and Exhibits <br />EXHIBIT A - Legal Description \~ <br />/\ <br />EXHIBIT B - Mining Plan , / <br />I <br />~ <br />EXH191T C - Map ~/ <br />/~ <br />~ <br />EXH IBIT D - Wild <br />ife, Water Resources, ~/ <br />r <br />Vegetation, SoilsVlnformation (J~ <br />