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.. _ ;_. • • <br /> ~II II~II~~II~I~I II~ <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Im act 110 Name S°• vey co. <br />P ( ) ' S+~ ~ sra P; r " <br />File No. M-~v-oR <br />Special 10-Day (111) Complete Filed) Date -tip a <br /> <br />ITEht COMPLETE ADEQUATE COMMENTS <br />Application Fonn: <br />1. Name of Operation <br />2. Name of Applicant (Operator <br /> X <br />3. Address & Phone (Local) <br /> X x <br />4. Address & Phone (General) <br /> X X <br />5. Person to Contact <br /> X )C <br />b. Surface Owners <br /> x ~ <br />7. Mineral Owners <br /> ~ ~ <br />i3. Source of Legal Right-To-Enter <br /> ~ x <br />y. Type of Mine/Substance <br /> X p~ <br />10. General Location 5 Elevation ~' "°`r ~°' ..:W <br /> g <br />D' ~dc4 f.J^? <br />11. County <br /> X x <br />12. Acreage <br /> ~ x <br />13. Fee ' <br /> <br />14. Present Land Use <br /> ~ ~ <br />15. Proposed suture Use ~ X <br />16. Siynature <br />_ gyn. _ r..~ <br />