HomeMy WebLinkAbout25IWC15 - DEEP Reporting Formrev. 1/2024 pdf
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 this form in accordance with the instructions on pages 2 and 3 and mail 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 I: Must Be Completed By The Inland Wetlands Agency
1.DATE ACTION WAS TAKEN: year: ______________month: ______________
2.ACTION TAKEN (see instructions - one code only): ______________
3.WAS A PUBLIC HEARING HELD (check one)? yes no
4.NAME OF AGENCY OFFICIAL VERIFYING AND COMPLETING THIS FORM:
(print name)(signature) ________________________________________________
PART II: To Be Completed By The Inland Wetlands Agency Or The Applicant
5.TOWN IN WHICH THE ACTIVITY IS OCCURRING (print name): _____________________________________________________
does this project cross municipal boundaries (check one)? yes no
if yes, list the other town(s) in which the activity is occurring (print name(s)): ____________________, ______________________
6.LOCATION (see instructions for information): USGS quad name: _______________________________ or number: __________
subregional drainage basin number: _______________________
7.
8.
9.ACTIVITY PURPOSE CODE (see instructions - one code only): ___________
10.ACTIVITY TYPE CODE(S) (see instructions for codes): __________, __________, __________, __________
11.WETLAND / WATERCOURSE AREA ALTERED (see instructions for explanation, must provide acres or linear feet):
12.UPLAND AREA ALTERED (must provide acres): ____________ acres
13.AREA OF WETLANDS / WATERCOURSES RESTORED, ENHANCED OR CREATED (must provide acres): ____________ acres
DATE RECEIVED: PART III: To Be Completed By The DEEP DATE RETURNED TO DEEP:
FORM COMPLETED: YES NO FORM CORRECTED / COMPLETED: YES NO
GIS CODE #: ____ ____ ____ ____ ____ ____ ____ ____ ____ For DEEP Use Only
NAME OF APPLICANT, VIOLATOR OR PETITIONER (print name): __________________________________________________
NAME & ADDRESS OF ACTIVITY / PROJECT SITE (print information): ________________________________________________
briefly describe the action/project/activity (check and print information): temporary permanent description: ____________
_______________________________________________________________________________________________________________________
wetlands: ____________ acres open water body: ____________ acres stream: ____________ linear feet