APPLICATION FOR PERMIT
MIDDLEBURY CONSERVATION COMMISSION/INLAND WETLANDS
MIDDLEBURY, CT 06762

Date Recieved _______ Fee Received________ Received by _________

Name of Development _____________________________________________

Location ______________________________________________________

Name of Applicant _________________________________________________

Business Address ________________________________________________

Home Address ___________________________________________________

Phone Number __________________

Contact Person __________________________________________________

Phone Number __________________

Name of Record Property Owner ____________________________________

Business Address ________________________________________________

Phone Number _________________________

Home Address ___________________________________________________

Phone Number __________________

1. Site Development Map should include:
   Total # of acres __________ Total # of wetland acres________
   
   1. Soil types shown and wetland boundaries to be indicated by shading
   2. Contour lines of five-foot intervals or less
   3. Existing watercourses both perennial and intermittent
   4. Appropriate setback line from wetlands and watercourses in distinctive colors
   5. Proposed relocation of watercourses or location and extent of proposed fill or excavation in all wetlands or regulated areas or watercourses
   6. Inset parcel location map (scale 1" - 1,000') and north arrow
   7. Identification of all adjacent property owners and appropriate mailing addresses for Public Hearing only.
   8. Location of proposed buuildings, wells, driveway and septic.
   9. Drainage systems and road profiles.
2. Nature and locaton of proposed activity in regulated area (appropriate setback inclusive)
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   
3. Amount of deposition of material in regulated area ___________________________
   
   1. type and toxicity of material _______________________________________
   2. Veritical height of deposition, including side-slope gradients after construction ____________
   3. Amount of excavated material in regulated area ___________________________________
   4. Type and tixicity of material ___________________________________________________
   5. Depts of excavation, including side-slope gradients after construction __________________
      
4. Include with application the following:
   
   1. Soils report
   2. Hydrology study
   3. Alternatives considered by the applicant and why the proposal to alter wetlands set forth in the application was chosen (include any mitigation measures)
5. It is understood by the applicant that submittal of any additional information may be deemed essential by the Commission. Further, the Agency may require posting of a performance bond in a sufficient amount to insure the proper completion of the approved acitivity.
   

Has application been previoiusly submitted? If so, under what name and date?

_________________________________________________________________________________________

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___________________________________________________
Signature of Applicant

___________________________________________________
Signature of Record Owner

*Note: The applicant is responsible for obtaining any federal, state or local permits as required by law.

**Note; Effective July 1, 1992, all towsn are required (under public act 82-235) to collect a $10.00 surcharge on behalf of the State of Connecticut D.E.P. for any person making an application for any approval,

Rev. 9/97