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7/78 APPLICATION CHECKL I ST • III III III IIIIIII III BD_ <br />LIMITED IMPACT (110) ~ NAMEP~O,c/L~E« (//c~~-.999 FILE r~ g~ <br />SPECIAL 10-DAY (111) _ COMPLETE (FILED) DATE ,% ~.~ ~~ <br />---------------------------------------------------------------------------------------------- <br />ITEM ~®~~ G ~/f~ /~ ~ COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator '~ <br />3. Address b phone, local <br />%~ <br />4. Address b phone, general ~ <br />5. Person to contact ' <br />6. Surface owners <br />\ <br />7. Mineral owners <br />8. Source of legal right-to-enter <br />9. Type of mine/substance <br />~ 1 <br />i <br />10. General location b elevation ~ <br />Y <br />11. County l ~ <br />12. Acreage ~' / \ <br />13. Fee <br />~ ~f 1 <br />14. Present land use ~ \ <br />15. Proposed future use <br />16. Signature <br />~/~ <br />~ ~ ~ `~ C L <br />hi i <br />d <br />s <br />Maps an <br />x <br />EXHIBIT A - Legal Description v , <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map <br />EXH IBIT D - Wildlife ter Resources,-/ <br />Vegetation,~ils Information (~ <br />