Inland Wetlands and Watercourse Agency

DATE OF RECEIPT:

TOWN OF CORNWALL

INLAND WETLANDS AND WATERCOURSE AGENCY

PETITION FOR DECLARATORY RULING

1.  Applicant(s) Name: ______

Res:______

Bus: ______

Phone Res: ______

Bus: ______

Email Address: ______

2. Owner(s) If same as applicant, so state.

Name: ______

Address Res: ______

Bus: ______

Phone Res: ______

Bus: ______

3.  Applicant(s) interest in land (owner, lessee, option holder, etc.)

4.  If applicant is not the owner, then the owner’s consent, duly acknowledged, to the proposed Activity, must be attached to the application.

5.  Location of Proposed Activity:

______

______

Detailed description or plot plan. (Additional page may be used)

Area (acres)______Square Feet, if less than 2 acres______

Assessor’s Map No. ______Parcel No. ______Zone______

Total acreage of wetlands on property. ______

6.  Purpose and description of the proposed activity:

______

______

______

7.  Any other information the Commission deems necessary to the understanding of what the applicant is proposing. As stated in Section 4.1 of the Cornwall Inland Wetlands and Watercourses Regulations as amended, such information includes the submission of a site plan, construction sequence and procedures, an erosion and sedimentation control plan, Best Management Practices for storm water controls, and any other such information that may be required by the Agency to be assured that the activity will have no adverse effect on other wetlands and watercourses in the State of Connecticut.

______

______

8.  Applicant’s Signature:

The undersigned warrants the truth of all statements made in conjunction with this application and consents to inspections of the site.

Applicant’s Signature Print or type name

Owner’s Signature:

The undersigned owner(s) of record consent to the submission of this application and to inspections of the site.

Owner’s Signature Print or type name

The Agency shall rule that the proposed operation and use is a permitted or a non- regulated use or operation (see Section 4 of the Cornwall Inland Wetlands and Watercourses Regulations) or that a permit is required. If the Agency determines that the proposed activity(s) is not a non-regulated use or operation and that a permit is required, an application in accordance with the provisions of Section 7 of the regulations shall be required.

For Agency Use:

Petition No. ______Date Received ______

Fee*** ______

Petition approved ______

Petition denied______

Petition granted with the following conditions:

______

______

______

______

Petition denied for the following reasons:

______

______

______

______

Chairman ______Date ______

Secretary______

***No fee if the Agency rules that the proposed operation and use is a permitted or a non-regulated use or operation (see Section 4 of the Cornwall Inland Wetlands and Watercourses Regulations). If the Agency determines that the proposed activity(s) is not a non-regulated use or operation and that a permit is required, an application in accordance with the provisions of Section 7 of the regulations shall be required and a fee submitted accordingly.

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