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\ 7/78 APPLICATION CHECKLIST III III III IIIIIIIIII <br />• • ses <br />REGULAR 112 APPLICATION <br />COMPLETE (FILED) DATE <br />FILE /1~~ /3~:- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br /> <br />Application Form: <br />1. Name of operation <br />(/ <br />2. Name of applicant <br />3. Address b phone, local <br />4. Address E phone, general <br />5. Person to contact <br />6. Parent Corporation, if any <br />I <br />7. Surface Owners <br />8. Mineral Owners <br />9. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance <br />Il. General Location E Elevation <br />12. Lounty <br />13• Acreage <br />14. Fee ~~ <br />15• Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature ~ -~o ~-o „~-" c'''~a-~ <br />~ ti~~l <br />(over) <br />