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4/77� - III III'll'll'lll'I I <br /> 999 <br /> MINED LAND RECLAMATION <br /> LIMITED IMPACT AND SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br /> File No. 77 Name G,I�cT Date of Filing (Completeness) : <br /> ITEM COMPLETE ADEQUATE COMMENTS <br /> Application Form <br /> 1. Name of operation �- <br /> 2. Name of applicant/operator <br /> 3. Address & phone (local offices) <br /> 4. Address & phone (general offices) <br /> 5. Person to contact V <br /> 6. Surface owners <br /> 7. :Mineral owners V <br /> 8. Type of mine/substance / <br /> 9. General location & elevation / <br /> 10. County <br /> 11. Acreage ✓ <br /> 12. Fee O.A. OWL <br /> 13. Present land use <br /> 14. Proposed future use <br /> 15. Signature <br /> Maps and Exhibits <br /> 1. Exhibit A - Legal description <br /> 2. Exhibit B - Lffining plan <br /> 3. Exhibit C - Map <br /> 4. Exhibit D - Wildlife, Water Resources, <br /> Vegetation and Soils infor- <br /> mation <br /> 5. Exhibit E - Reclamation plan <br />