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4/77 . '~I'I"II'II"II'II • <br />MLVED LeV~1D RECLAMATION <br />LIMITED IPIPACT AND SPECIAL 10-DAY PERMIT APPLICATION C:IECKLIST <br />nr ,n: ~i_... <br />File No. 1~~ Name Date of Filing (Completeness):lll,__(7fti <br />ITEM COMPLETE ADEQUATE COtQiEi3TS <br />Application Form <br />1. Name of operation <br />~ <br />-~~~ ~-~p,~ -~ ~'1- <br />vu.r~ L <br />2. Name of applicant/operator J <br />3. Address S phone (local offices) ~" <br />4. Address & phone (general offices) ~' <br />5. Person to contact <br />6. Surface owners V <br />7. PLtneral owners ~/ <br />8. Type of mine/substance v <br />9. General location ~ elevation <br />I0. County V <br />11. Acreage <br />12. Fee <br />13. Present land use v <br />I4. Proposed future use ~ <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />2. Exhibit B - inning plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Water Resources, <br />Vegetation and Soils infor- <br />mation ~ ~1011Q2t <br />I <br />~. Exhibit E - Reclamation plan ~/ <br />