Laserfiche WebLink
7/78 APPLICATION CHECKLIST III III III IIIIIIIIII <br /> sss <br /> REGULAR 112 APPLICATION NAME �Q�1��` Poww�aGo FILE N7y-S,Z <br /> COMPLETE (FILED) DATE Li ,a , I-I'F56 <br /> ------------------------------------------------------------------ ---�!'---- ---------------- <br /> ITEM COMPLETE ADEQUATE COMMENTS <br /> Application Form: <br /> 1 . Name of operation <br /> 2. Name of applicant C j > <br /> 3. Address b phone, local <br /> G= <br /> 4. Address 5 phone, general <br /> 5. Person to contact / <br /> 6. Parent Corporation, if any <br /> v <br /> 7. Surface Owners <br /> v � <br /> 8. Mineral Owners <br /> 9. Source of Legal Right-to-Enter / <br /> r <br /> 10. Type of Mine/Substance v �� <br /> 11 . General Location b Elevation <br /> 12. County v <br /> 13. Acreage <br /> 14. Fee / <br /> 15. Present Land Use <br /> 16. Surrounding Land Uses V <br /> 17. Proposed Future Use <br /> 18. Unpermitted Mining Operations <br /> 19. Affected Lands (/ <br /> 20. Signature <br /> (over) <br />