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4/7~ • • III IIIIIIIIIIIII III <br />MINED LtV~D RECLAPfATION <br />LIPIITED ITH'ACT APID SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br />Di u. HWNss D•5~, ~/ <br />File No. ~7 7~Name IYOKP ~tn ['1u (~ Date of Filing (Completeness): <br />ITEM COMPLETE ADEQUATE COMAfENTS <br />Application Form <br />1. Name of operation <br />5 /p 7 <br />// <br />2. Name of applicant/operator I <br />3. Address 5 phone (local offices) <br />.5 1 '7 <br />4. Address b phone (general offices) 5 /7 <br />5. Person to contact <br />.S r7 <br />6. Surface o~mers y,-//, <br />7. PLineral owners <br />_ <br />5 ~'7 <br />8. Type of mine/substance <br />S r7 <br />9. General location E elevation $. <br />10. County ~ ~ <br />11. Acreage /~ <br />12. Fee ~ ~7 <br />13. Present land use 5/r~ <br />14. Proposed future use ~/~,/ <br />15. Signature ~~~.~ <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />S <br />2. Exhibit B - Pfining plan <br />3. Exhibit C - Pfap ~ r <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Soils infor- <br />motion ~//7 ~-"~/arrj <br />5/~~ NZ 0 <br />5/x'7 ~~`j' <br />5. Exhibit E - Reclamation plan // n <br />