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4/77 . • <br />MIbTED LAND RECLAMATION <br />LIMITED TYD?ACT AND SPECIAL IO-DAY PERMIT APPLICATION CHECKLIST <br />File No.~~ Namer,'S~p„r }~i'f - j~;~.~/„~y,S Date of Filing (Completeness): <br />ITE1 COMPLETE ADEQUATE COMMEi1TS <br />Application Form <br />1. Name of operation <br />~ <br />Z. Name of applicant/operator /~~ ,7 <br />/ <br />3. Address & phone (local offices) 5~ <br />4. Address 6 phone (general offices) <br />5. Person to contact <br />6. Surface owners ~ <br />7. iiineral owners ~ /} <br />S. Type of mine/substance ~ <br />9. General location h elevation <br />10. County /~ g <br />11. Acreage <br />12. Fee aj <br />13. Present land use ~ <br />14. Proposed future use ~/2 <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />~jl <br />Z. Exhibit B - :fining plan Q <br />3. Exhibit C - Map 2 C~ <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Soils iafor- <br />oration <br />2 <br />S. Exhibit E - Reclamation plan ~~ <br />