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4/77 III IIIIII'III'll 'll <br /> MINED LAND RECLAMATION <br /> 999 <br /> LIMITED IMPACT AND SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br /> ,y- <br /> File No. 7A—'9­�e Name Date of Filing (Completeness) : <br /> ITEM COMPLETE ADEQUATE COMMENTS <br /> Application Form <br /> 1. Name of operation <br /> v <br /> 2. Name of applicant/operator <br /> 3. Address & phone (local offices) <br /> V <br /> 4. Address & phone (general offices) <br /> 5. Person to contact <br /> 6. Surface owners <br /> 7. Mineral owners ✓ i <br /> 3. Type of mine/substance <br /> i <br /> 9. General location & elevation <br /> d <br /> 10. County V <br /> 11. Acreage <br /> 12. Fee <br /> 13. Present land use <br /> V <br /> 14. Proposed future use <br /> 15. Signature <br /> �s and Exhibits <br /> 1. Exhibit A - Legal description <br /> 2. Exhibit B - Mining plan <br /> 3. Exhibit C - Map <br /> 4. Exhibit D - Wildlife, Water Resources�,V <br /> Vegetation and Soils infor- <br /> mation " <br /> 5. Exhibit E - Reclamation plan V i/ <br />