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7/78 APPLICATION CHECKLIST <br /> REGULAR 112 APPLICATION III 1111111111111111 <br /> FILE # 77--`,"/ <br /> ETE (FILED) DATEs�G <br /> 999 /z ') <br /> ITEM COMPLETE ADEQUATE COMMENTS <br /> Application Form: <br /> 1 . Name of operation <br /> 2. Name of applicant Ll <br /> 3. Address & phone, local <br /> 4. Address & phone, general <br /> 5. Person to contact <br /> 6. Parent Corporation, if any <br /> 7. Surface Owners <br /> 8. Mineral Owners <br /> I <br /> 9. Source of Legal Right-to-Enter /- <br /> 10. Type of Mine/Substance <br /> 11 . General Location & Elevation <br /> i <br /> 12. County <br /> 13. Acreage <br /> 14. Fee <br /> 15. Present Land Use L--- <br /> 16. Surrounding Land Uses <br /> 17. Proposed Future Use <br /> 18. Unpermitted Mining Operations .- <br /> 19. Affected Lands v <br /> r <br /> 20. Signature <br /> (over) <br />