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4/77^ <br />6 ~[ r 78 <br />`TED LAiiD ?tECLATL4TI0i`.T <br />LL*1ZTED L`IPACT AiII? S2°CL9L 10-OAY P°_Ri?IT ?~pPLIC2.TI0.7 CT'•.ECaZ.IST <br />File Va. >~ Name 7 //~if p-~~~~ Date of Filing (Completeness) <br />ITS C0:lPT.ETE I ADEQL'ATZ ( CO~~TTS <br />Avvlication Form <br />1. ;Tame of operation /~ <br />2. Name of apalicaat/operator / <br />3. Address ~ phone (local offices) <br />I <br />w. Address S phone (oeaeral offices) <br />5. Person to contact / <br />~. Surface ocraers I / I ~ <br />i. :Siaeral owners ~ <br />I / , <br />i <br />8. Type of ~':,e/substance ~ <br /> f <br />I <br />9. General location & elevation ~ ,/ <br />10. County I / <br />i i ~-y f7~ c~ ~S~.v~t.d <br />. i <br />_ Acreage `/ •cc ~~ Wtia1 s ,gyp <br />I2. Fee y(fes' ~ ~""~. <br />i3. ?reserc land use ~ ~, ~ <br />i+. ?roposed future use ~ <br />( ~SJ,c~~d ,nd,ca~-t: ,rub <br /> vim I ~,~~ uJtc. ct~~e(' /eciuwa.~-,1 <br />15. 513aature I/ <br /> <br />:ans and y.•thibits j meli,~Js of ~rn~~~ 'W ~`' <br />QmP~ QJ ~~ ~GS~ i~-c~gR-- <br />i <br />d a~ o~etu ~-, w, <br />+ <br />a `,r <br />p <br />escript <br />on <br />1 .\hibit .~ -Legal ~ <br />JP <br />i <br />Z. F:chibit B - :.iaiag plan I ~ <br />/A~ ~eY ~~ mer a w/, <br />iV {%ota S,7R ~t UfCU <br />3. =.zhibit C - :yap ( / <br />/ I ' wor <br /> <br />,. c,syib:C D - '.iildlif z, :~atez Qesources, ~ <br />etation`~ nd Soils ±a:cr- <br />7e <br /> <br />/ <br /> <br />~ ISo ft~4 Some wig ~~ <br />saes f~L+e urea. ~~,o} <br />, Rio <br />lab <br />~ <br />-F-~ <br />g ~~„ <br />~ <br />~* . <br />w <br />ak~ ,Mpo. <br />J <br />nation ~ e .vu <br />cu~ <br /> <br />~ S.t o~ .,a.c, s a <br />} leg <br />4 vw <br />7. t~hib it °_ - 3eclamatioa pl.:a I / ~ , <br />~~ ~ <br />s 1 <br />