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4/77 <br />MP7ED LAa`1D RECLAti4TI0i7 <br />LIMITED IPIPACT AND SPECIPy 10-DAY PERi3IT APPLICATION CHEC:~IST <br />File No. ~7-S.i . ame 5 c.G~,.-~i a~'-' ~~ o-q0 Date of Filing (Completeness) <br />ITE'1 CO~LL•TE ADEQUATE COMr1ETTS <br />Application Form <br /> <br />1. Name of operation <br />~~ <br />2. Name of apnlican.t/operator ~~ <br />3. Address fi phone (local offices) <br />i ~/~ <br />4. Address 5 phone (general offices) <br />S. Person to contact <br />5. Surface ocmers v I <br />7. :iineral owners ~^ <br />8. Type of mine/substance <br />9. General location & elevation ~~ <br />I0. County /~i <br />11. Acreage I <br />I2. eee <br />i3. Present land use [,/ <br />I4. Proposed future use I / <br />G I <br />15. Signature L/~ <br />P7aps and Exhibits <br /> <br />1. Exhibit A - Legal description <br />L/'~ <br />2. Exhibit B - =?iaing plan G/~ <br />3. xhibic C - 2~.an <br />=•. Exhibit D - 'dildlife, (dater Resources, <br />7egetatioa and Soils infor- <br />mation <br />5. c.4hibit E - Reclamation plan I ~~ I <br />