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7/78 APPLICATION CHECKLIST III IIIIII IIIIIII III <br />sss ?cr('- a g 3 <br />LIMITED IMPACT (110) ~! NAME t,~a,(5•='~-~^ J`~-Cr-- FILE N~ <br />SPECIP.L 10-DAY (111) _ COMPLETE (FILED) DA <br />---------------------------------------------------------------------------------------------- <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address & phone, local v <br />4. Address ~ phone, general <br />5. Person to contact ~~ <br />6. Surface owners ~ <br />// <br />7. Mineral owners <br />8. Source of legal right-to-enter Nc.~~ <br />9. Type of mine/substance <br />10. General location E elevation ~ <br />11. County !/ <br />12. Acreage ~' <br />13. Fee <br />L <br />14. Present land use <br />15• Proposed future use L <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description _ <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map ~~~`~ C~c'`''t'(~~' <br /> <br />EXH BIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information ~_ <br />-- <br />