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~/~$ APPLI_C_AT_LON CHECKLIST "•7~-v~~ <br />7N - <br />LIMITED IMPACT (110) ~ _ III III III IIIIIIIIII FILE ~ /r7 <br />SPECIAL 10-DAY (111) _ 999 E (FILED} DATE <br />------------------------------------------------------------------------ J------- ~ --- YU~ ---- <br />ITEM COMPLETE ADEQUATE COMMENT ~ aJ <br />,i~- i ~ <br />Application Form: Z~ <br /> <br />1. Name of operation <br />/ <br />}/ o` <br />~ a Y a ~ `~ <br />~ ~e~ J~ ) <br /> <br />2. Name of applicant/operator <br />, / /, ~ <br />'`~~~ <br />3• Address & phone, local <br />4. Address b phone, general <br />V <br />5. Person to contact / <br />6. Surface owners 1~ <br />7. Mineral owners v <br />8. Source of legal right-to-enter / <br />9. Type of mine/substance <br />10. General location E elevation / <br />\ <br />/ <br />11. County l <br />V <br />12. Acreage / <br />1/ <br />13. Fee ~' <br />14. Present land use <br />15. Proposed future use / <br />v <br />16. Signature / <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />/ <br />EXHIBIT B - Mining Plan , / <br />V <br />EXHIBIT C - Map / <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information <br />