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<br /> ~; <br />,,, , <br />MTirED LaxD RECLAMATION / ~ _ ~ _ 7 7 ~~ ~ ( " <br />//'' LI24ITED IPIPACT AND SPECIAL 10-DAY PERI~fST APPLICATIOir CHECKLIST <br />File No.777~~Name/1/f0/`~J~z°5E Cot~NT~ Date~~f6f Filing (Completeness): <br />ITE."f COMPLETE ADEQUATE COMME:iTS <br />Application Form <br />1. Name of operation <br />~- <br />2. Name of applicant/operator [~ <br />3. Address 6 phone (local offices) ~ <br />4. Address & phone (general offices) ~~~ <br />5. Person to contact ~ <br />5. Surface owners ~~ <br />7. ,Mineral owners ~ <br />8. Type of mine/substance ~ <br />9. General location 6 elevation <br />10. County ~l <br />11. Acreage L~ <br />12. Fee <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 - Mining plan ~~ <br />3. Exhibit C - Map C~ <br />4. Exhibit D - Wildlife, ~~Sdat}}r P.esources,`'~ <br />Vegetatio~ad Soils infor= i <br />mation <br />f- _ -~ <br />5. Exhibit E - Reclamation plan ~ ~ <br />