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7/78 III IIIIIIIIIIIIIIII •PPLICATION CHECKLIST c:~w,~~ ~ 1 <br />sss <br />REGULAR 1 ] 2 APPLICATION NAME IeP (.r1tl~~ ~6 ~ G ~I'C y~~ r ~ _ L <br />COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br /> <br />3• Address b phone, local / <br />4. Address E phone, general t~ <br />i <br />5. Person to contact ~ <br />6. Parent Corporation, if any <br /> c-"" ~ <br />7. Surface Owners <br /> b~° <br />8. Mineral Owners ~ <br /> <br />9• Source of Legal Right-to-Enter <br /> R~ <br />10. Type of Mine/Substance <br /> <br />11. General Location E Elevation <br /> l s' <br />12. County <br /> 6/ <br />13• Acreage <br /> ~• <br />14. Fee <br /> <br />15. Present Land Use ~ <br />16. Surrounding Land Uses ~ <br />17. Proposed Future Use <br /> <br />18. Unpermitted Mining Operations <br />~.~'. <br />19• Affected Lands y~ <br />20. Signature ~ <br />(over) <br />