1 July 2017 – 30 June 2018
GST exempt
FORM NO. GEN 04v7
APPLICATION FOR PERMIT FOR A WATER AFFECTING ACTIVITY
RESPECT OF A WATERCOURSE, FLOODPLAIN OF A WATERCOURSE, LAKE OR BANK OF A LAKE
Pursuant to Section 135 of the Natural Resources Management Act 2004
Applicant to Complete - please write in CAPITAL BLOCK letters.
* Denotes mandatory information required.
*APPLICANT DETAILSTitle: Mr Miss Ms Mrs Dr Other (please specify):
*Name:
Company Name: (if applicable) / ACN:(if body corporate)
*Address:
*Postal Address:(if different from above)
*Phone: / Mobile: / Fax:
Email:
* PROPERTY DETAILS (attach a copy of CERTIFICATE of TITLE to application – do not provide originals)
*Certificate Title: Vol:Folio: / *Street No:
*Street:
*Suburb: / *Postcode:
*Allotment No: / *Plan No:
*Section: / *Hundred:
Property Name / CFS Rapid Number
*PROPERTY OWNER DETAILS (if different from applicant)
Title: Mr Miss Ms Mrs Dr Other (please specify)::
*Name:
*Address:
*Postal Address:(if different from above)
*Phone: / Mobile: / Fax:
Email:
OFFICE USE ONLY
Date received: / Ref No: RM / Payment enclosed: Yes No
File No: / Document No:
Council Area: Kangaroo Island / Additional Info Required: Yes No / Receipt number
Approved: Yes No / Decision Notification Sent: Yes No / CITB Fund Levy Applies : Yes No
Nature of Water Affecting Activity
3(d) / 5(b) / 5(d) / 5(f) / 5(h)
5(a) / 5(c) / 5(e) / 5(g) / 5(k)
* DETAILS of PROPOSED WORKS TO BE UNDERTAKEN
Please provide a detailed description of works to be carried out.( i.e.details of proposed building or structure)
______
Please provide details of all materials to be used
______agnew______
Please state your reason(s) for undertaking the works (i.e. erosion control)
______
REMOVAL OF VEGETATION
WILL VEGETATION GROWING IN A WATERCOURSE, FLOODPLAIN OF A WATERCOUSE, LAKE OR BANK OF A LAKEBE AFFECTED OR DESTROYED AS PART OF THE PROPOSED ACTIVITY?
YES NO
Ifyou tickedYES
Please provide a detailed description of vegetation you are proposing to remove
______
Please state the purpose of removal
______
Please describe the method of removal and measures to be undertaken to protect the watercourse, lake or floodplain
______
MOVEMENTOF ROCK, SAND OR SOIL
WILL THE PROPOSED ACTIVITY INCLUDE THE EXCAVATION OR DEPOSITION OF ROCK, SAND OR SOIL?
Rock YES NO
Sand YES NO
Soil YES NO
Ifyou ticked YES to any or all
PLEASE PROVIDE A DETAILED DESCRIPTION OF THE PROPOSED EXCAVATION/DEPOSITION
______
______
______
PLEASE STATE THE PURPOSE OF THE PROPOSED EXCAVATION/DEPOSITION
______
PLEASE DESCRIBE THE MEASURES THAT WILL BE PUT IN PLACE TO PROTECT THE WATERCOURSE, LAKE OR FLOODPLAIN. TO ASSIST YOU IN COMPLETING THIS SECTION, YOU MAY WISH TO ACCESS INFORMATION ON SEDIMENT CONTROL MEASURES WITHIN THE EPA’s, Code of Practise for Building & Construction Sites. htttp://
______
* GENERAL RISKS TO WATER QUALITY, WATERCOURSE INTEGRITY & ECOSYSTEMS
Please identify risks to water quality, watercourse integrity or water dependant ecosystems associated with the proposed ACTIVITY. This includes the excavation and stockpiling of rock, sand or soil during works.
______
______
______
______
______
DESCRIBE HOW THESE RISKS WILL BE MITIGATED
______
______
______
* OTHER APPROVALSWHAT, IF ANY, APPROVALS DO YOU OR YOUR COMPANY HAVE FROM OTHER STATE OR LOCAL GOVERNMENT AGENCIES TO CONSTRUCT OR ENLARGE THE PROPOSED DAM?
______
______
______
* CONSTRUCTION INDUSTRY TRAINING BOARD LEVYIS THE VALUE OF THE PROPOSED WORKS IN EXCESS OF $15,000? ? YES NO
IF YES, PLEASE PROVIDE A COPY OF YOUR RECEIPT FROM THE CONSTRUCTION INDUSTRY TRAINING BOARD (CITB) INDICATING THAT THE ASSOCIATED CONSTRUCTION INDUSTRY TRAINING FUND (CITF) LEVY HAS BEEN PAID.
Note: Permit approval can not be granted without the evidence that the CITF levy has been paid (if applicable).
For further information refer to the Construction Industry Training Board website
*WORKS PLANYou must provide a Site Plan and drawing(s) with your application that include the following information
- Site Plan
- North arrow and approximate scale
- The boundaries and divisions of the land and any relevant easements
- Significant features such as houses, sheds, trees and adjoining roads
- Key geographic features such as all watercourses, drainage lines, lakes and wetlands; slope of the land; contours; direction of water flow; floodplain etc.
- Existing dams and bores
- The position and dimensions of the proposed WAA and distance to the site boundaries and other features such as trees that might be affected by the work;
- The precise location of the proposed works to be carried out stating the approximate distances to property boundaries
- The level of the structure in relation to any street or watercourse;
- Where relevant, the location of side entry pits to discharge points (spillway);
- The location and type of sediment control measures proposed both during the construction phase and following construction
- Native vegetation that will be retained or enhanced and any vegetation proposed to be removed.
- Detailed Drawing(s)
- All information necessary to describe the size and nature of the proposed works
*DECLARATION / SIGNATURE
NOTE: The applicant must complete ONLY ONE of the following:
I/We declare that the information that has been provided on this application is true and correct.
SIGNED:
- Where the applicant is an individual or two or more persons
Signature______Print Name______Date______
Signature______Print Name______Date______
- Where the applicant is a Company or an Incorporated Association
EITHERThe seal of
)
)
)
)
)
(Name of Company or Incorporated Association)
WAS HEREBY AFFIXED IN THE PRESENCE OF
Name(s)______Position______
Signature______Date______
OR A person or persons duly authorised to sign for and on behalf of
(Name of Company or Incorporated Association)
Name(s)______Position______
Signature______Date______
Return application and payment to:Attn: Water Officer
Kangaroo Island Natural Resources Management Board
Natural Resources Centre
PO Box 39
Kingscote SA 5223
Enquiries: KI Natural Resources Management Board, 37 Dauncey Street, Kingscote, 8553 4444
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