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4/77 <br /> <br />MINED LAND RECLA-L4TION I <br />LIMITED II•IPACT AND SPECIAL 10-DAY PERilIT APPLICATION CHECKI+IS <br />File No. ~ Name ~'D Date of Filing (Completeness): <br /> <br />ITEM COMPLETE ADEQUAT~ OMMENTS <br />Application Form <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address S phone (local offices} <br />4. Address & phone (general offices) <br />S. Person to contact <br />6. Surface owners <br />7. .fineral owners <br />8. Type of mine/substance <br />9. General location 5 elevation <br />I0. County <br />11. Acreage <br />12. Fee <br />13. Present land use c/~ <br />14. Proposed future use ~~ <br />15. Signature <br />~s and Exhibits <br />1. Exhibit A - Legal description <br />2. Ew'~ibit B - Mining plan ~~ <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Water Resources, <br />oegetation aad Soils infor- <br />mation <br />5. Exhibit E - Reclamation plan <br />i <br />~~~~ <br />pp ~~I <br />.tiY ~ ~ I itl <br />!. <br />