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4/77 <br />• iii iiniiiiniii iii • % ~ - . , ~. <br />MINED LAUD RECLAMATIOtI /~,~ _~ _ 7 7 ~ ~~ <br />LIMITED I2~IPACT P.ND SPECIAL 10-DAY PERMIT APPLICATION CHECS~,IST <br />File No.77 ~7Name~it//oiY" ~9~fj;~G ~~Date of Filing (Completen¢as):~~ -T 77 <br />ITE."1 COMPLETE ADEQUATE COMMENTS <br />Application Form <br />1. Name of operation <br />2. Name of applicant/operator v <br />3. Address S phone (local offices) <br />4. Address & phone (general offices) <br />5. Person to contact L! <br />6. Surface owners f <br />7. t3ineral owners ~ <br />8. Type of mine/substance (~ LJ,F J f'~i <br />9. General location S elevation <br />10. County <br />11. Acreage ~. ~. 9 <br />12. Fee <br />13. Present land use (~- <br />14. Proposed future use <br />15. Signature ~/ <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />!~ <br />2. Exhibit B - :Siring plan LI <br />3. Exhibit C - Map (~ <br />4. Exhibit D - Wildlife, Sdater Resources,' <br />Vegetation and Soils infor r/ <br />oration <br />7. Exhibit E - Reclamation plan <br />