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~/~s ~ <br />LIMITED IMPACT (110) '~ III <br />SPECIAL 10-DAY (111) <br />----------------------------- <br />ITEM <br />APPLICATION CHECKLIST <br />NAME fa 7'f ~r.a-hTv~rdr~ers" Gsc.Ne~~ {- ~7%- <br />Pan -Yrr~ cE, •~ o- F f L E #~_ <br />'IIIIIIIIIIII II COMPLETE (FILED) DATE <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br /> <br />1. Name of operation <br />i <br />2. Name of applicant/operator <br />3. Address b phone, local <br />/ <br />; <br />4. Addressv phone, general ~ <br />5. Person to contact ,~ <br />i <br />6. Surface owners <br />7. Mineral owners ~/ <br />8. Source of legal right-to-enter <br />9. Type of mine/substance ~ <br />10. General location 6 elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present land use <br />15. Proposed future use `, <br />16. Signature ~~ / <br />Maps and Exhibits <br /> <br />EXHIBIT A - Legal Description <br /> <br />/ <br />i~ <br />EXHIBIT B - Mining Plan / // <br />EXHIBIT C - Map / <br />EXH IBIT D - Wi ldl i e Water Res9urces.~ <br />Vegetation; Soils Information`s <br />