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4"'- - • • ~~ir rirriiri~rrrrr~r <br />999 <br />MINED LA~vD RECLAMATION <br />/~//11 LL`TiTED IPiPACT AND SPECIAL 10-DAY PERI~±IT APPLICATI0,1 CHEChZ]:ST JJ <br />File No. ll'1'fJ Name 1D~Y~~. ~?J'ZG. Date of Filing (Completenes:~): ~~~71~~ <br />ITEM COMPLETE ADEQIIATE COI~1MEr1TS <br />Application Form <br />1. Name of operation <br />,~ <br /> <br />~ln. ~ <br />2. Name of apolicaat/operator ~ ~~~ Pit <br />3. Address b phone (local offices) <br />4. Address 6 phone (general offices) ~/ <br />5. Person to contact <br />6. Surface owners <br />1. rfiaeral owners <br />8. Type of mine/substance <br />9. General location ~ elevation ~ <br />lo. county ~/ <br />11. Acreage <br />12. Fee ~/ <br />13. Present land use <br />I4. Proposed future use ~ ' <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Le3a1 description - / <br />V <br />2. Ew'~ibit B - Mining plan <br />3. Exhibit C - ;fop <br />4. Exhibit D - Wildlife, Slater Resources, <br />Vegetation and Soils infor- <br />motion <br />/ <br />V <br />5. Exhibit E - Reclamation plan <br />