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<br />-2- <br /> <br />3. Address and Phone Number of X378 ~i~0 Rd <br />Local Offices pAO^~ "~ ~ ~O o ~ ~J a-q <br />aa7-4434- <br />4. Address and Phone Number of <br />General Offices S A'~ <br />5. Name and Phone Number of Person aATR,G~A F-A 2NS iJ°PTN <br />Staff Members Should Contact Sd7- 4 43 •! o~ S a 7- 3 d-~ g <br />6. Owner(s) of Record of Affected Land l?A~pH L, I,t/,~son! <br />(surface area) (If more than 2, list below) <br />7. Owner(s) of Substance to be Mined RALPH ~ 1~S/~~so.J <br />(If more than 2, list below) <br />8. Source of Legal Right-To-Enter <br />(Indicate what type of proof is <br />included in EXHIBIT G - lease, <br />deed, notarized letter, etc.) <br />9. Type of Mine and Substance to be Mined o Per- ~ ~ r <br />(Specify underground, open pit, <br />quarry, etc. & substance(s) to SAND ~ G-PAJE.I <br />be mined) <br />10. General LOC ation and Elevation ~ ^~~~6 1A/c57 0~ aNO Nin oN 1~(• F. GJAJN~S°^~ <br />(Miles & direction from nearest Q;,,t¢ 14x5 4005 L,~., I~AON~a,@ APPa~~ <br />town & approximate site elevation) <br />59ooFr E~EJ, <br />11. County ~E ~ , A <br />12. Acreage of Affected Lands <br />(Total surface acreage to be ~, A-3 A c. <br />included in permit) <br />13. Application Fee (See applicable <br />Rule to determine amount) <br />