Request for land use planning advice
TO: / Land Use Planning Coordinator
Regional Services Division
Department of Environment Regulation
Locked Bag 33
CLOISTERS SQUARE WA 6850
Or email:
FROM: / Local Government Authority:
Officer name:
Position: / Phone:
Email:
DATE: / LGA Ref:

Please complete all parts of the form by selecting the relevant box and filling in the detail where required.

Type of referral/application:

Requested response date:

Note: The Department of Environment Regulation (DER) generally requires a minimum of three weeks to consider a referral

Has this application been referred to DER in the past?

Yes – when:
No

Does the application involve the clearing of native vegetation?

Yes
No

If a proposal involves clearing of native vegetation a clearing permit is required in accordance with the Environmental Protection Act 1986 (EP Act), unless the clearing is of a nature described in Schedule 6 of the EP Act or the Environmental Protection (Clearing of Native Vegetation) Regulations 2004. For assistance in determining if an exemption applies please contact DER’s Native Vegetation Conservation Branch on 6467 5200 or email . DER does not review land use planning applications in regard to clearing of native vegetation.

Is the application for a prescribed premises, or a premises that has the potential to become prescribed?

Yes
No
Prescribed premises means all prescribed activities listed in Schedule 1 of the Environmental Protection Regulations 1987. A copy of these regulations can be accessed at www.slp.wa.gov.au

.

Why are you referring this application to DER for environmental advice? Please select:
An Environmental Protection Notice or Pollution Abatement Notice is recorded against the site.
The application area has a high risk of acid sulfate soil disturbance.
The application is for a harbour, marina or canal estate.
The application indicates the site is classified under the Contaminated Sites Act 2003 as:
contaminated – restricted use
contaminated – remediation required
remediated for restricted use
possibly contaminated – investigation required
The application indicates the site may be a contaminated site. Please specify a reason for this determination:
The application may be affected by or cause significant impacts through:
noise and/or vibration. Please specify why this may be an issue:
odour. Please specify why odour may be an issue:
dust. Please specify why dust may be an issue:
emissions and/or discharges. Please provide further detail:
The application indicates the site is next to a sensitive land use. Please provide further detail:
The application indicates the site is in or next to an environmentally sensitive area. Please provide further detail:
The application indicates the site is in an area covered by an Environmental Protection Policy. Please provide further detail:
Other, please specify:
Do you have any other comments?