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4/77 • • III III III IIIIIIIIII <br />MIMED LAND RECLAMATIOtI <br />LL*ffTED II`tPACT r1DID SPECIAL 10-DAY PERi~IT APPLICATION CEECKLIST <br />File No. Name Date of Filing (Completeness): <br />ITE,'`i COMPLETE ADEQIIATE COMMEdTS <br />Application Form <br /> <br />I. Name of operation <br />i ~ <br />~ ~(~.,~,~~~`13'v"~/- <br />ANN l1~~I1 //IIddLL ~I rJ{ <br />2. Name of applicant/operator / <br />3. Address fi phone (local offices) <br />4. Address & phone (general offices) <br />5. Person to contact <br />5. Surface owners ~ I <br />i <br />7. Mineral owners <br />8. Type of mine/substance <br /> <br />9. General location S elevation i <br />I <br />"^'~'}^^~~"` <br />10. County / <br />11. Acreage <br />I2. c'ee <br />13. Present load use I / <br />14. Proposed future use / <br />i <br />15. Signature ~/ <br />caps and Exhibits <br />1. Exhibit A - Legal description <br />,, <br />Z. Exhibit B - 2.ining plan <br />3. Exhibit C - Map <br />~~. Exhibit D - '+Iildlife, water Resources, <br />7egetation and Soiis iafor- <br />mation I ""~`b"^"^^ <br /> <br />~ <br />5. E.:hibit E - Reclamation olaa ~ <br />