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7/7° ~ APPLICrT!Ctl C-~CXLIST <br />~F, yl Lok•s G.,~~el Pa dc, " <br />LIMITED IN,PACT (I10) ~, NA~kE SeHtl,,~,e3t io e~f.'~s~rae• FILE ? i- 58 <br />SPECIAL 16-DAY (lit) CD"PLETE (FILED) DATE <br />ITEM COMPLETE ADE^~UATE CDHMENTS <br />Application Form: <br />1. )lame of operation ~ <br />2. flame of applicant/operator ( <br /> X <br />3. Address l; phone, local <br /> ~ ~ <br />4. Address 6 phone, general <br />5. Parson to contact <br />f <br />6. Surface owners ~ <br />7. Mineral owners I jG I <br />8. Source of legal right-to-enter I <br /> ~ <br />°. Type or mine/substance I <br /> ~ ~ <br />ID. General location b elevation <br />11. County <br />12. Acreage I <br />1 Q~eb~bly .-e~< rti~- s~ PeKhoFr <br />~. <br />1 j. Fee + 975 f~a +, aY .eY 6~ ..,u_9h <br />14. Present land use <br /> <br />15. Proposed future use <br />i <br />16. Si;nature ( <br /> ~ <br />Moos and Exhibits <br />EXHIBIT A - Legal Description <br />EXHIBIT B - Mining Pian <br /> To*u ~ ~K~ p~h4 spy ..,r s4~~~, <br />EXH I S IT C - Map <br />J J N..d o, w, <br />F - 1 <br />YH 31T D ai ldl~ re, `rater a <br />scurces WutN ufC s y'r.}., y.1-i1w ~/. SGY P <br />~ <br />~ <br />, <br />Vegetation, Soils Information ~ *. <br />u~•+ s, c.z ,.-.~rT <br />