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7/]$ <br />. APPLICATION CHECKLIST ~ <br />3q...rs L•:.~. ~~lo~~ III IIIIIIIIIIIIIIII <br />LIMITED IMPACT (110) ~ NAME ~ ~ +-' -~ %~~'" sss <br /> <br />SPECIAL 10-DAY (111) _ <br />CCMPLETE (FILED) DATE _ <br />/''la,_;~ 5 . I~.:'J <br /> <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation X <br />2. Name of applicant/operator <br /> ~ \ / <br />J~ <br />3. Address & phone, local <br />4. Address 6 phone, general <br /> X <br />5. Person to contact <br /> ~~ <br />6. Surface owners ~ ~ / <br />?. Mineral owners ~ ~ <br />8. Source of legal right-to-enter <br />~- <br />\ <br /> \ <br />9. Type of mine/substance ~~ <br /> ~~ <br />10. General location E elevation v ~ <br /> <br />ll. County x ~ <br />;~ <br /> . <br />12. Acreage J <br /> ~~ i <br />13. Fee <br />14. Present land use \ <br /> <br />X ~ <br />15. Proposed future use `` <br />i <br />16. Signature <br /> r <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map <br /> <br />EXH IBIT D - WildlJfe, Water Rj ources, <br />Ve <br />etati <br />il <br />S <br />I <br />f <br />i <br />g <br />on, <br />o <br />s <br />n <br />ormat <br />on <br />