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7/78 APPLICATION CHECKLIST <br /> REGULAR I ];' APPLICATION NAME W77-IA/GHA• StU A �G F I LE N I9-3S� <br /> COMPLETE (FILED) DATE <br /> ----------- ----------------------------------------------------------------------------------- <br /> h?/CYCr <br /> ITEM COMPLETE ADEQUATE COMMEN <br /> Application Form: <br /> 1 . Name of operation <br /> 2. Name of applicant a//a <br /> 3. Address & phone, local /a7/o' <br /> 4. Address & phone, general <br /> 5. Person to contact <br /> I <br /> 6. Parent Corporation, if any N/q <br /> 7. Surface Owners <br /> I <br /> 8. Mineral Owners <br /> 9. Source of Legal Right-to-Enter / o' <br /> 10. Type of Mine/Substance <br /> 11 . General Location & Elevation <br /> 12. County //o' <br /> 13. Acreage f II <br /> 14. Fee <br /> 15. Present Land Use <br /> 16. Surrounding Land Uses <br /> 17. Proposed Future Use <br /> 18. Unpermitted Mining Operations <br /> 19. Affected Lands <br /> 20. Signature /lam <br /> (over) <br />