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4/77 ~ • <br />MT.i1ED LAND RECLAMATION <br />LIMITED IMIIPACT AND SPECIAL 10-DAY PERi~tIT APPLICATION CHECkZ IST <br />File No. Name ~o brc~ ~i,~vc~y(eS Date of Filing (Completeness):. <br />ITEM COMPLETE ADEQUATE COMPIENTS <br />Application Form <br />1. Name of operation <br />/~ <br />Z. Name of applicant/operator <br />3. Address 6 phone (local offices) <br />4. Address b phone (general offices) <br />5. Persoa to contact <br />6. Surface ocmers ~/ <br />7. itineral owners <br />8. Type of mine/substaace ~/ <br />S. General location ~ elevation <br />10. County <br />~/ <br />11. Acreage Cf <br />12. Fee <br />13. Present land use ~ <br />14. Proposed future use V <br />I5. Signature ~/ <br />~s and Exhibits <br />1. Exhibit A - Legal description <br />~,/ <br />4 ~ -7 <br />1 <br />2. Exhibit B - dining plan ~ <br />3. Exhibit C - Map ~ <br />4. Exhibit D - Wildlife, Water ResouriC~es, <br />Vegetation'~and Soils/infor- <br />matioa <br />5. Exhibit E - Reclamation plan / <br />