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7/78 APPLICATION CHECKLIST <br />iii iiiiiiiiniii iii <br />sss <br />I <br />LIMITED IMPACT (110) NAME~_ FILE a Sy 3 <br />SPECIAL 10-DAY (111) COMPLETE (FILED) U <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operaltion <br />2. Name of applicant/operator / <br />3. Address ~ phoine, local v <br />4, Address b phoine, general C~ <br />5. Person to conitact ~ <br />6, Surface owne ris C/ <br /> <br />7. Mineral owne I <br />rls <br />~ <br />8, Source of le gal right-to-enter ~~ <br />9. Type of mine substance <br />10. General loca tion & elevation <br />11. County v_ <br />12. Acreage ~ <br />13. Fee // <br />14. Present land use ~~ <br />15. Proposed fut ire use <br />16. Signature <br />Maps and Exhibit s <br />EXHIBIT A - Legai Description <br /> <br />EXHIBIT B - Mini <br />i g Plan / <br />1/ <br />EXHIBIT C - Map <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information ~ i <br />i~ <br />