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7/78 <br />LIMITED IMPACT (110) ~ ~' <br />SPECIAL 10-DAY (111) _ <br />IT-cM <br />APPLICAT~D~I C~EC<LIST III IIIIIIIIIIIIIIII ~~- <br />NAME Qn~.-~~~rr'~ C,'•.-...-•~ - sss FILE r /o/ <br />COMPLETE (FILED) DATE ~_,~ ~ /9~/ <br />COMPLETE ADEQUATE COMMENTS <br />Aoolica*_ion Form: <br />1. Name of operation // ~ <br />~ 2 I <br />2. Name o. =cpiicant/operator <br />~/ <br />3. Address E pnone, ',--a1 I <br />4. Address E phone, general I / I <br />5. Person to contact ~ <br />I I ~ <br />f I <br />6. Surface owners I / <br />(/ <br />7. Hineral owners I ` <br />~ <br />I <br />8. Source of legal right-ta-enter I , / <br />9. Type of mine/substance I <br />10. Genera! location b elevation ~ 4 <br />11. County <br />i <br />I / <br />12. Acreage ~ <br />i / <br />(/ <br />13. fee <br />14. Present land use <br />I <br />15. Proposed future use ~ I / I <br />16. Signature ~ <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />~ 1 /// <br />V _ <br />EXHIBIT B - Mining Pian , / <br />EXHIBIT C - Map V <br />EXH i31T D - Wildlife~4later Resailrces, // <br />Vegetatiori~ Soils Information I J (~ <br />