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~l~s <br />APPLICATION CHECKLIST <br />• • <br />REGULAR 1 12 APPLICATION II I III III I II IIII III ~yud~ .Gcc.«~~i, ~o~C /1 FILE 11 7j - / 9S <br />sss ETE (FILED) DATE O~ 3/. ~%7/`' <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant ~ <br />3. Address b phone, local ~~ <br />4. Address b phone, general L~ <br />5. Person to contact `~ <br />I <br />6. Parent Corporation, if any J <br />7. Surface Owners <br />~i <br />8. Mineral Owners ~ <br />9. Source of Legal Right-to-Enter ~~ <br />10. Type of MinelSubstance <br />11. General Location E Elevation <br />12. County (/ <br />13. Acreage <br />14. Fee _~ <br />15• Present land Use <br />16. Surrounding Land Uses <br />`~ <br />l7. Proposed Future Use ~ <br />18. Unpermitted Mining Operations ~~ <br />19. Affected Lands v <br />20. Signature L/ <br />(over) <br />