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T -- _ _ _ <br />_7/78 ~ APPLICATION CHECKLIST III III III IIIIIII III <br />REGULAR 1 12 APPLICATION ~ NAME S= ~• ~-s J;.P '° ; LE N ~° ~ `~/ <br />C/!r yil <br />COMPLETE (FPLED) DATE ,3~i/~fJv <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant v <br />3• Address E phone, local L` <br />4. Address 6 phone, general cl <br />I <br />5. Person to contact L/ <br />6. Paren*_ Corporation, if any ~_ <br />7. Surface Owners L_ <br />8. Mineral Owners <br />C, <br />9. Source of Legal Right-to-Enter ~ <br />~~ <br />10. Type of Mine/Substance ~~ <br />11. General Location b Elevation ~~ <br />12. County ~. <br />13. Acreage L~ <br />14. Fee ~ <br />15. Present Land Use <br />v <br /> <br />16. Surrounding Land Uses <br />`~ _ <br />17. Proposed Future Use ~-~ <br />18. Unpermitted Mining Operations c~ <br />19. Affected Lands ~~ <br />20. Signature L~ <br />(over) <br />