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;s APPLICATI0~1 c~~c;:L~~l III IIIIIIIIIIIIIIII~ <br />MITED IMPACT (110) ~ • NAMEEI I'oto ~ov.,~ P:YS .999 <br />ECIAL 10-DAY (lll) _----------------------COMPLETE (FILED)-DATE S e~ to _, b__ a _~-/S 80'_`'"__~. <br />EM <br />COMPLETE ADEQUATE COMMENTS ~,,t ~~ <br />plication Form: <br />Name of operation <br />Name of applicant/operator <br />Address 6 phone, local ~~ <br />Address E phone, general <br />Person to contact <br />Surface owners <br />Mineral owners <br />Source of legal right-to-enter <br />Type of mine/substance <br />. General location 6 elevation <br />. County <br />Acreage N ~ {~ ~ ~ d ~ ~: Au p ~ <br />Scr~u9P~ <br />. Fee <br />. Present land use <br />. Proposed future use <br />. Signature <br />~s and Exhibits <br />II BIT A - Legal Description -. ,. <br />II BIT B - Mining Pian <br />iIBIT C - Map . <br />J J <br />I bIT D - Wildlife, Water Resources, <br />Vegetation, Soilsr Information <br />