APPLICATION/LICENCE NO:

(amendment or renewal only)

• 1. NAME AND MAILING ADDRESS OF APPLICANT

  TELEPHONE: FAX:

• 2. ADDRESS OF HEAD OFFICE IN CANADA IF INCORPORATED

  TELEPHONE:FAX:

• 3. LOCATION OF UNDERTAKING (describe and attach a map, indicating watercourses and location of any proposed waste deposits)

  Latitude Longitude

• 4. DESCRIPTION OF UNDERTAKING (describe and attach plans)

• 5. TYPE OF UNDERTAKING

  • 1. Industrial

  • 2. Mining and milling

  • 3. Municipal

  • 4. Power

  • 5. Agriculture

  • 6. Conservation

  • 7. Recreation

  • 8. Miscellaneous (describe) 8.

• 6. WATER USE

  • To obtain water
  • To cross a watercourse
  • To modify the bed or bank of a watercourse
  • Flood control
  • To divert water
  • To alter the flow of, or store, water
  • Other (describe)

• 7. QUANTITY OF WATER INVOLVED (litres per second, litres per day or cubic metres per year, including both quantity to be used and quality to be returned to source)

• 8. WASTE DEPOSITED (quantity, quality, treatment and disposal)

• 9. OTHER PERSONS OR PROPERTIES AFFECTED BY THIS UNDERTAKING (give name, mailing address and location; attach list if necessary)

• 10. PREDICTED ENVIRONMENTAL IMPACTS OF UNDERTAKING AND PROPOSED MITIGATION

• 11. CONTRACTOR AND SUB-CONTRACTORS (names, addresses and functions)

• 12. STUDIES UNDERTAKEN TO DATE (attach list if necessary)

• 13. PROPOSED TIME SCHEDULE

  Start date Completion date

NAME  (Print)TITLE  (Print)SIGNATUREDATE

APPLICATION FEE         Amount: $ Receipt No.:

WATER USE DEPOSIT   Amount: $ Receipt No.: