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7,78 � APPL 'IIIIIIIIIIIIIIIIIII <br /> REGULAR 112 APPLICATION 9nv,mt I,- ve�e ILE 'f 3oZ <br /> COMPLETE (FILED) DATE /Z�30 �/ <br /> ------------------------------------------------------------------------- :c:>/ --------------- <br /> ITEM COMPLETE ADEQUATE COMMENTS <br /> Application Form: <br /> 1 . Name of operation <br /> 2. Name of applicant L <br /> 3• Address b phone, local <br /> 4. Address b phone, general <br /> 5. Person to contact <br /> 6. Parent Corporation, if any J'- <br /> 7. Surface Owners <br /> 8. Mineral Owners <br /> 9• Source of Legal Right-to-Enter <br /> 10, Type of Mine/Substance <br /> 11 . General Location b Elevation <br /> 12. County <br /> 13. Acreage I <br /> 14. Fee �K <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 <br /> (over) <br />