Application For Environmental Permit Chapter 167 "Wetland And Water Course Protection" Form - Town Of Somers, Westchester County, New York
ADVERTISEMENT
17/02
TOWN OF SOMERS
WESTCHESTER COUNTY, NEW YORK
APPLICATION FOR ENVIRONMENTAL PERMIT
CHAPTER 167 "WETLAND AND WATER COURSE PROTECTION"
APPLICATION FEE:
Alteration of Wetlands: $200 minimum fee plus $100 per 5,000 S.F. of regulated area or proposed portions
thereof to be disturbed.
Annual Maintenance Permit Renewal Fee: Administrative Permit: $25.00, Planning Board Permit:
$75.00
OWNER:
___________________
Tel.#: _____________________________
Mailing Address:___________________________________________________________________
APPLICANT:
_________________ _ Tel. #: ______________________
_
Mailing Address:__________________________________________________________
State authority: _________________If other than owner, authorization must be submitted in writing.
PREMISES: Sheet:
Block:
Lot:
_______
Situated on the
side of
_________________________ (Street),
feet from the
intersection of
________________________________ (Street)
DESCRIPTION OF WORK AND PURPOSE:_________________________________
_________
_____________________________________________________________________________________________
____________________________________________________________________________________
SIZE OF ACTIVITY AREA:
___
Is work proposed in Wetland:________or Wetland Control Area:______________
Is there an existing house located on the site:___________________________
Is pond, lake or detention basin proposed to be cleaned:__________________
Functions provided by Wetland:____________________________________________
Wetland Expert delineating Wetland:_______________________________________
ESTIMATED QUANTITY OF EXCAVATION:
__C.Y.
CUT
__ FILL
ESTIMATED TOTAL VALUE OF WORK:______________________________________________
PROPOSED STARTING DATE:
PROPOSED COMPLETION DATE:_________
PLANS PREPARED BY:
DATED:___________
**Plans must be submitted with application.**
LIST OF APPLICABLE COUNTY, STATE, OR FEDERAL PERMITS:_____________________
______________________________________________________________________
____
__________________________________________________
______
LIST OF PROPERTY OWNERS OF RECORD OF LANDS AND CLAIMANTS OF WATER RIGHTS
WITHIN 100 FEET OF SUBJECT PROPERTY
NAME
ADDRESS
BLOCK
LOTS
_____________________________________________________________________________________________
___________________________________________________
____
APPLICANT'S SIGNATURE:
DATE:
___
OWNER'S SIGNATURE:___________________________ DATE:____________________
*APPLICATION MUST BE ACCOMPANIED WITH A COMPLETED ENVIRONMENTAL ASSESSMENT
FORM, COMPLETE PLANS FOR LOT IMPROVEMENTS, AND LOCATION MAP OF WETLANDS AS
THEY EXIST IN THE FIELD OR AS SHOWN ON SOMERS ENVIRONMENTAL MAPS.
………………………………….............................Office Use Only………………………………..........................
Administrative Permit:_______________
Planning Board Permit:________________
C:\My Files\Somers_P&E_Wetlands_2002-07.DOCC:\My
Files\Somers_P&E_Wetlands_2002-07.DOC
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Environmental Permit Chapter 93 "stormwater Management And Erosion And Sediment Control" Form - Town Of Somers, Westchester County, New York
Legal
Application For New Water And/or Sewer Service Form - Town Of Peterborough Public Works - Utilities Division
Legal
Form 12 - Application For Group/position Peace Officer Authority And Status - Sunrise Provision - Colorado Department Of Law
Legal
Related Categories
Parent category: Legal