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<br />7/78 APPLICATION CH ECKL I ST III IIIIIIIIIIIIIII <br />sss I </~_ <br />LIMITED IMPACT (110) _ NAME//~~~•y~~~~~ FILE N~~ <br />SPECIAL 10-DAY (111) _. -` COMPLETE (FILED) DATE /',/pf/ ~7; //r7~ <br /> <br />-------- <br /> <br />ITEM ----------------------- <br /> <br />~L_Ll Sow ---------------------- - <br />- --------------------------- <br />/L~; ~~~ COMPLETE ADEQUATE COMMENTS <br />------------ <br />Application Form: <br />1. Name of operation <br />/ <br />2. Name of applicant/operator <br />/ <br />3. Address b phone, local ~ <br />4. Address b phone, general <br />5. Person to contact ~ <br />6. Surface owners i <br />i I~ <br />7. Mineral owners <br />;\ <br />8. Source of legal right-to-enter <br />i <br />9. Type of mine/substance ~' <br /> <br />10. General location 6 elevation \ <br />1 <br />Il. County ; <br />12. Acreage <br />i <br />13• Fee _ <br />//J '< <br />14. Present land use <br />15• Proposed future use <br /> <br />16. Signature ., <br />~ <br />i <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />[~ <br />EXHIBIT B - Mining Plan ,' ~ <br />EXHIBIT C - Map ~- <br />EXH IBIT D - Wildlife, Waser Resources,/ <br />Vegetation, Soils Information's - <br /> <br />