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7/78 / <br />LIMITED IMPACT (110) ~% • <br />SPECIAL 10-DAY (111) _ <br />ITEM <br />APPLICATION CHECKLIST /~ III III III IIIIIIIIII ~~_ <br />~ 03 <br />NAME 8~~"`- / ~NS%~' 999E I LE # <br />COMPLETE (FILED) DATE_ ~/UNE7f /rj7~j <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address E phone, local / <br />4. Address & phone, general / <br />5. Person to contact <br />6. Surface owners / <br />7. Mineral owners / <br />8. Source of legal right-to-enter / <br />9. Type of mine/substance / <br />10. General location &. elevation ~ <br />11. County I/ <br />12. Acreage / <br />13. Fee <br />14. Present land use 1/ <br />15• Proposed future use i/ <br />16. Signature / <br />Maps and Exhibits <br />EXHIBIT A - Legal Description ~• ~' ~ <br />EXHIBIT B - Mining Plan / <br />EXHIBIT C - Map <br />EXH IBIT D - Wi Idl i fe`, Water Resources <br />Vegetation, Soils Information ~/ <br />