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7/78 ~ APPLICATION CHECK''L//IS//T/~ • <br />REGULAR 112 APPLICATION NAME ~T ~ l`~'~+ +' ~"J~ F I LE ~ FS~~ - <br />COMPLETE (FILED) DATE i9 K Z <br />ITEM <br />COMPLETE ADEQUATE COHMENTS <br />App <br />I. lication Form: <br />Name of operation <br />2. Name of applicant <br />3. Address S phone, local <br />4. Address S phone, general / <br />l/ <br />5. Person to contact / <br />Y I <br />6. Parent Corporation, if any / <br />`/ <br />7. Surface Owners <br />8. Mineral Owners / I I <br />Y <br />I <br />3• Source of Legal Right-to-Enter / <br />/ V~aq.~ q~QEEn1EN~ <br />10. Type of Mine/Substance / <br />I/ <br />Il. General Location ~ Elevation <br />12. County / <br />13• Acreage / I ~ . ~ <br />14. Fee <br />15• Present Land Use <br />16. Surrounding Land Uses / <br />/ <br />~• <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature / <br />(over) <br />