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4/77 <br />MIIiED LAND RECLAMATIOt1 <br />iii iiiiiiiiiiiu iii <br />LIMITED IDIPACT A.W SPECIAL 10-DAY PERi~!IT APPLICATION C$ECKLIST <br />File No.~77-311 Name Cdf~=~ C~~p 5,E i3 ,q Date of Filing (Completeness): <br />ITEM COifPLETE ADEQUATE COMMENTS <br />Application Form <br />1. Name of operation <br />Z. name of applicant/operator ~/ <br />3. Address & phone (local offices) <br />4. Address & phone (general offices) <br />5. Person to contact <br />6. Surface owners r/ I <br />7. ilineral owners !~ <br />8. Type of mine/substance <br />4. General locatioa S elevation <br />10. County <br />11. Acreage <br />12. Fee `^~'`~ <br />13. Present land use / <br />i/ <br />14. Proposed future use <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />2. Exhibit B - :fining plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Tdater''Resources, <br />beget ion and So3Xs infor- <br />mation <br />5. Exhibit E - Reclamation plan <br />