APPLICATION FOR PERMIT MINIMAL ACTIVITY FORM 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 __________________

1. Location of Proposed Activity ________________________________________
   
   
2. Description of nature and extent of proposed activity (include amounts of deposition or excavation within setback area)
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3. A plot plan showing exten of activity shall be provided
   
   
4. It is understood by the applicant that submittal of any additional information may be necessary for a determination by the Wetlands Enforcement Officer.
   

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Signature of Record Owner

 

*If approval is graned, in accordance with section 22a-42a XX (2), of the Connecticut General Statues, the applicant shall publish notice of such approval within ten days of approval in a newspaper having general circulation in the Town of Middlebury