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4/77j • <br />~dED LAND RECLAMP.TION ~ III III III IIIIIIIIII <br />LIIfITED L*D?ACT AND SPECIAL IO-DAY PERiiIT APPLICATIO:T CHEC:Q,IST <br />File No. 1'10 ;lame T~O~a n S uv7 /3i~c , i ~f ~ t-Date of Filing (Completeness) <br />I1'~I CO:~LETE ADEQIIATE C0~41E2TT5 <br />Application Form <br />I. Name of operation <br /> <br />/ <br />2. Name of applicant/operator <br />3. Address 6 phone (local offices) / <br />4, Address 6 phone (general offices) / <br />5. Person to contact ~/ <br />5. Surface owners , I <br />i <br />7. 24iaeral owners <br />8. Type of mine/substance ~ <br />9. General location S elevation ~ I <br />I0. County / <br />II. Acreage <br />/ <br />~ <br />IZ. Fee ,' <br />I3. Present land use <br />I / ~ <br />14. Proposed future use ~ ~ <br />i <br />15. Signature <br />~+aps and Exhibits <br />1. Exhibit A - Legal description q ~<< ~ ~. - <br />Z. Exhibit B - fining plan <br />3. Exhibit C - yao <br />'i. Exhibit D - Wildlife, (dater Resources, <br />7egetatioa and Soils infor- <br />mation <br />5. E.~:hibit E - ?.eclamation plan <br />