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4/77 <br />MINED Lr4~fD RECLAMATIOi1 <br /> <br />LIMITED L*fPACT A~VD SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br />File No. '9.73? ~ Name -.7t,vrv~r~i~ 'Pre~dl ~+* i[~(, Date of Filing (Completeness) <br />ITE:i COMPLETE ADEQUATE COMMEi1TS <br />Application Form <br />1. Name of operation <br />~ <br />2. Name of applicant/operator f <br />3. Address 6 phone (local offices) / <br />4. Address & phone (general offices) / <br />5. Person to contact ~ <br />5. Surface ocaners / I <br />7. itineral owners ~/ <br />S. Type of mine/substance /- <br />9. General location S elevation /' <br />10. County /~ <br />11. Acreage <br />. <br />Q A.L <br />12. Fee ~ <br />13. Present land use ~" <br />14. Proposed future use ~ <br />15. Signature ~,/ <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />>~ <br />~a~,- <br />\`p(~ ,~ <br />Z. Exhibit B - .lining plan ,~ <br />3. Exhibit C - Map ,/' <br />4. Exhibit D - Wildlife,,/Slater Resourc , <br />Vegetatio~nd Soils~fnfor- <br />mation <br />5. Exhibit E - Reclamation plan / <br />