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<br />4,7,-, . ~ a III <br />MINED LAP1D RECLAMATIOP7 <br />LIMITED 71~D?ACT AND SPECIAL 10-DAY PERI~!IT APPLICATION C°ECKLIST <br />File No. 77- wN Name M- ~,~ Lo ~ ~ Date of Filing (Completeness) :_ <br />IIIIIiilllllllii <br />ITEM COMPLETE ADEQUATE COMMEiTTS <br />Application Form <br />1. Name of operation J / <br />v <br />2. Name of applicant/operator <br />3. Address S phone (local offices) <br />4.. Address S phone (general offices) <br />5. Person to contact ~ <br />6. Surface owners <br />7. .Siaeral owners <br />8. Type of mine/substance <br />9. General location & elevation ~ <br />10. County <br />11. Acreage C/ <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 v <br />2. Exhibit B -inning plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Sails infor- <br />mation v <br />5. Exhibit E - Reclamation plan <br />