HomeMy WebLinkAboutCT Reporting Form • •Connecticut Department of
GIS CODE#:
ENERGY & For DEEP Use tnly
ENVIRONMENTAL
MMIIIIII PROTECTION
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79 Elm Street•Hartford,CT 06106-5127 www.ct.gov/deep Affirmative Action/Equal Opportunity Employer
Statewide Inland Wetlands & Watercourses Activity Reporting Form
Please complete and mail this form in accordance with the instructions on pages 2 and 3 to:
DEEP Land&Water Resources Division, Inland Wetlands Management Program,79 Elm Street, 3rd Floor,Hartford, CT 06106
Incomplete or incomprehensible forms will be mailed back to the inland wetlands agency.
PART 1; `.Must:Be:Completed By The Inland Wetlands,-Agency
1. 'DATE ACTION WAS TAKEN: year: - . :month: -
2. ACTION TAKEN_ see instructions,-onl use one:.code
3.: 1NAS.A PUBLICHEARING HELD(check one)?• yes 0 no- ❑
4.- NAME OF AGEN Y O F- A -V
C O FICI L ERIFYINGAND:COMPLETING THIS•
FORM: -
-
(pnnt name) ,
_ '(signature)_
I. To Be.Completed B The Inland;Wetlande.,"# .enc �.Or 1The A licant: ::';_
5. :TOWN IN WHICH.THE ACTION IS OCCURRING;:(print:narrie): .<. !J''r I/-i L - : ,-:- ,
does this project cross municipal boundaries(check one). yes 0 .- no
es list the e
oth r town s in which h . '
t e action is=occurrn:::-`rint name s��: '-':;':;;; ? . ,~; ; , =.. ..:<_°;.=::,,:.;::::;r;''>�"•;',';;..; ..:,":;;. . . :;.
v
see.instructions for information):,:•,USGS:quad:name`.::``�/i- :,,.::: . ._ . or,number:. ..
s e ,
ubr •oval drai a "
i n e-basin.number.'�
7. NAMEOA
F PPLIC- VIOLATO.3-_.::'---:_9,:,....r-:
OR PETITIONER not name e0;0-4.C1!' i .:-,-:-,:„i,.,,
-`
8. NAME&ADDRESS I LOCATION_:OF PROJECT SITE(print information) /5 7 1)O'r'LE"(i, „•:'44„-1 ;r,li-Ui -" '
briefly describe theappipiojectiddvitl;(0d5"ai0:Ort*° 01'9) t _PP9Ta7° =7'71aA64mAelglfg003_ : :::,..,.-r_,--:--.:.--:.:.,:.;.',,::-.,-;r:r-.-i
o ); •'YEODE(see instructions,:only useone cde: , -
_9. ACTIVIT .PURPOSC -
10. ACTIVITY 7YPE.CODE S see.instrucUonsfor cotles : . ,-., .. ,
11. WETLAND -
W
/ ATERCOURS A
E .REA ALTS •E
R D. mush` rovide acres�or'�' e r=
Itn a-.feet
wetlands: -,7,77,:c?,,,: �:,r0— n e:;
waferbody;:::': . ' .. . '.acres �; -:<.:`::�;;str•eam . ;:.-.;,:_;, :..;, linear feet'. �.
12.
UPLAND
AREA ALTERED
must rovideacre
s U=•��'O..
acre - -
13. AREA OF WETLANDS'/WATERCOURSES RESTORED ENHANCED OR-CREATED,(m`ust provide:acres) acres.,
DATE RECEIVED: PART Ill:;=To Be:Completed. yT
Bhe<DEEP DATE RETURNED TO'-DEEP:
' FORM COMPLETED: YES:-_NO _ _ _ FORM°CORRECTEDICOMPLETED:` YES =NO
rev.1/2019 pdr