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7/78 • APPLICATION CHECKLIST • <br />REGULAR 112 APPLICATION NAME g~T,!_._-, ~~...~41~.-FILE ~~'~-~o <br />COMPLET~ ) DATE ~i1~u9 / ~ / 9 $~/ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant ~ <br />3. Address l; phone, local ~~ <br />4. Address 6 phone, general <br />5. Person to contact f~ <br />I <br />6. Parent Corporation, if any J~ <br />I <br />7. Surface Owners <br />8. Mineral Owners I <br />3• Source of Legal Right-to-Enter <br />10. Type of Mine/Substance <br />ll. General Location E Elevation <br />12. County / <br />~ I ~ <br />13. Acreage <br />1 4. Fee - - <br />15• Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermittad Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />