APPLICATION FOR PERMIT
MAINTENANCE & RESTORATION
MIDDLEBURY CONSERVATION COMMISSION/INLAND WETLANDS
MIDDLEBURY, CT 06762 Date Recieved _______ Fee Received________ Received by _________
Name of Applicant _________________________________________________
Home Address ___________________________________________________
Phone Number __________________
Business Address ________________________________________________
Phone Number __________________
- Location of Proposed Activity ________________________________________
- Nature and extent of proposed activity_________________________________
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- Expected Commencement ___________ Expected Completion ______________
- Estimated amount & type of material to be excavated (in cubic yards) ___________
Estimated amount & type of material to be deposited (in cubic yards) ___________
- Attached plot plan at maximum scale of 1" = 40' showing approximate location of all wetlands, watercourses, setback areas, existing buildings, septic systems, well and drainage systems, (culverts, footings and curtain drains). Show area of proposed activity, area of spoil disposition and proposed erosion control devices.
- To construct or alter dam or spillway, attach profile, cinstruction dimensions and design approval from Department of Environmental Protection, Water Resources Unit.
- It is understood by the applicant that submittal of any additional information may be deemed essential by the Commission.
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Signature of Record Owner
Rev. 9/97