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7/78 • APPLICATION CHECKLIST ~ 'II'I"I"I"""II1 ~_ <br />REGULAR 1 12 APPL I CAT l ON NAME C.1). ~~ : I- ~~S ),err 7 ~ -)' F I LE #~ <br />COMPLETE (FILED) DATE 9~/ <br />----------------------------------------------------- ------- -------- -------- ------------------ <br />1T EM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />4'l~9 <br />2. Name of applicant <br />3. Address ~ phone, local <br /> 9 <br />4. Address 6 phone, general <br /> 4 9 <br />5. Person to contact <br />6. Parent Corporation, if any ~ <br /> 9 9 1 <br />7. Surface Owners <br /> v <br />8. Mineral Owners <br /> 9 r <br />9. Source of Legal Right-to-Enter <br /> <br />10. Type of MinejSubstance <br />11. General Location E Elevation <br />12. County <br /> 9 <br />13. Acreage <br /> <br />14. Fee <br /> <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br /> 9 <br />19. Affected Lands <br />20. Signature <br /> <br />(over) <br />