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7/78 APPLICATION CHECKLIST III IIIIIIIIIIIIIIII <br />• sss <br />REGULAR 112 APPLICATION NAMEr~•..-~?r: ~ r ~' G" F I LE /l 7y -Y <br />COMPLETE (FILED) DATE <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />v <br />2. Name of applicant ~. <br />3• Address & phone, local l/ <br />4. Address E phone, general <br />5. Person to contact <br />6. Parent Corporation, if any ~ ~ <br />7. Surface Owners <br />8. Mineral Owners `~ <br />9• Source of Legal Right-to-Enter ~ <br />10. Type of Mine/Substance <br />11. General Location b Elevation <br />12. County `~ <br />13. Acreage (/ <br />14. Fee ~' <br />15. Present Land Use (.~ <br />16. Surrounding Land Uses 2~ <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations ~ ^ <br />19. Affected Lands <br />20. Signature <br />(over) <br />