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4/77 _ <br />~ III IIIIIIIIIIIIIIII <br />999 <br />t~iTED Lr1iVD RECLAMATIOtI <br />~,(,~vw} <br />•~"" Ge w <br />LIMITED L`IPACT ARIpD SPECIAL 10-DAY PFRi?IT APPLICaTIOV CHECKLIST <br />File Na. __ "lame ~~,Vivr fi' - ~-c-~.4~ ~ Date of Filing (Completeness) :. <br />ITE:1 COMPLETE I ADEQIIA'"E C0;4SEiTfS <br />Application Form <br />I. Name of operation <br />2. :lame of applicant/operator / <br />/ <br />3. Address 6 phone (local offices) ~ <br />4. Address 6 phone (general offices) f / <br />S. Person to contact <br /> <br />5. Surface ormers <br />I I <br />7. Pliner,il owners ~ <br />S. Type ~~f mine/substance <br />9. General location ~ elevation <br />L0. county ~ <br />11. Acreage ~ <br />1Z. tee <br />I3. Present laced use ~ <br />I4. Prancsed future use I ~ <br />l5. Sigas.ture ~~ <br />;laps and Exhibits <br />1. E.ehibit .~. -Legal description <br />,~ <br />Z. Ex.'ribit B - ~liaiag plan •/ <br />3. Exhi~it C - uap <br />4• . E:chi~it D - 'dildlif ldater R~sources, <br />Tlegetat~ and ,oils i,-afor- <br />aation <br />S. E,~rhi;~it E - 3eclamation plan ,~ ~ <br />