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7/78 APPLICATION CHECKLIST <br /> n QO— <br /> LIMITED IMPACT ( I10) v NAMEFED,/ Lri� 'GG-5 COO�� FILE171 <br /> SPECIAL 10-DAY (111 ) _ COMPLETE (FILED) DATE i9//G. <br /> ITEM v'fr- L <br /> COMPLETE ADEQUATE COMMENTS <br /> Application Form: <br /> 1 . Name of operation <br /> 2 . Name of applicant/operator <br /> 3. Address & phone, local <br /> 4. Address & phone, general \ <br /> 5. Person to contact / <br /> 6. Surface owners / r/ <br /> 7. Mineral owners <br /> 8. Source of legal right-to-enter \ / <br /> 9. Type of mine/substance <br /> 10. General location & elevation `\ <br /> 1 <br /> 11 . County / <br /> 12. Acreage I <br /> 13. Fee J <br /> 14. Present land use <br /> 15. Proposed future use / J <br /> 16. Signature 7 <br /> Maps and Exhibits - <br /> EXHIBIT A - Legal Description <br /> EXHIBIT B - Mining Plan <br /> EXHIBIT C - Map <br /> EXH IBIT D - Wildlife, Water Resources , _ �l <br /> Vegetation , Soils Information <br />