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7/78 III III III IIIIIII III • APPLICATION CHECKL I ST <br />Mo,.v1~f. N~:IC p1:x~ - r, <br />REGULAR 112 APPLICATION NAME "Chrmbt. ~ d:'i FILE #7S-ao5 <br />COMPLETE (FILED) DATE Nov. ate. /575 <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />~lication Form: <br />1. Name of operation <br /> x <br />2. Name of applicant <br /> <br />3. Address 6 phone, local <br /> X <br />4. Address b phone, general X <br /> X <br />5. Person to contact <br />X <br />x <br /> <br />6. Parent Corporation, if any X <br /> <br />7. Surface Owners <br />8. Mineral Owners x <br />9. Source of Legal Right-to-Enter ~ ~ <br /> <br />10. Type of Mine/Substance X <br />11. General location & Elevation x <br /> <br />12. County <br /> ,x <br />13. Acreage X (~ <br />/\ <br />14. Fee \/ <br />/~ <br />l5. Present Land Use <br />,~ <br />.~ <br />16. Surrounding Land Uses X `/ <br />/` <br />17. Proposed Future Use ~ ~~ <br />18. Unpermitted Mining Operations X <br /> <br />19. Affected Lands X <br />20. Signature ~/ <br />(over) <br />