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7/7$ • APPLICATION CHECKLIST III III IIIIIIIIIIIII <br />999 <br />REGULAR 1 12 APPLICATION NAME ~'~~-~ d + •~~%..e 7n,.LC~t. F I LE ¥ Y ~ -/iL <br />COMPLETE (FILED) DATE //~.2 b~b~.2 <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br /> <br />2. Name of applicant Nv~ ^7e~,< <~~sr.-<*•.~ ~~. <br /> <br />3. Address E phone, local / <br />/ <br />4. Address & phone, general <br />5. Person to contact <br /> <br />6. Parent Corporation, if any <br /> / t <br /> <br />7. Surface Owners <br />~ _ <br />8. Mineral Owners / <br />/ <br />9. Source of Legal Right-to-Enter / <br /> <br />`/ x <br />10. Type of Mine/Substance I <br />11. General Location E Elevation <br />12. County <br /> / <br />13. Acreage ~3 n<.as ct,o<r ~.r~fao. <br /> <br />14. Fee <br />/ <br />~ ~ <br />~Y70 <br />od ~8 <br />° <br /> i . <br />~0 00 <br />15. Present Land Use ~ <br />x <br /> I <br />16. Surrounding Land Uses <br /> <br />17. Proposed Future Use ~ <br /> / x <br />18. Unpermittad Mining Operations <br /> <br />19. Affected Lands <br /> <br />20. Signature <br />(over) <br />