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~- <br />,/,? ~ =P III IIIIIIIIIIIIIIII: ~ 5 ~~--" ~ ~~- <br />LIMITED IMPACT (110) X NAME F[LE ~ <br />SPECIAL 10-DAY (I 11) _ COMPLETE (FILED) DATE /}a~ 1 ~ ~~$~ <br />IT-cH COMPLETE ADEO,UATE COMMENTS <br />Aoolicacion Forn: ` <br />1. Name of operation I <br />~/ <br />2. flame of applicant/operator ~ f <br />3. Address b phone, local t/ <br />I <br />4. address b phone, general v I f <br />5. Person to contact ~~ ) I <br />! <br />6. Surface ewnnrs ` <br />f <br />7. nineral owners I ~ <br />S. Source of legal right-to-enter I ~I <br />q. Type of mineJsubstance ~ _~1 <br />10. General lceation b elevation I <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present land use <br />15• Proposed future use <br />i <br />16. Signature <br />Hops and Exhibits <br />EXHIBIT A - Legal Description - <br />EXHIBIT 8 - Mining Pian <br />EXHIBIT C - Hap / <br />EXH .BIT D - 4ildlife, 'mater fiescurces, <br />Ve etation, Soils Information ~ ~/ ` <br />