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06/337654 March 2011
Application for an assessment of environmental affects
Please complete this form to the best of your ability and include with your resource consent
application form.
Proposal
What are you proposing to do
Note Where possible please use diagrams and plans drawn to a recognised scale to detail the proposal
Site description
What is the area of the site
What is the topography of the site (flat/rolling/sandy/wetland etc)
What is the vegetation contained on the site
Are there any existing buildings on the site
Yes No
If yes, please describe and provide a site plan showing their location and any access to these buildings
Are there any special features on or near the site? (e.g.
archaeological sites/notable trees/historic buildings)
Yes No
If yes, please describe
Note If you are unsure regarding the possibility of historic sites, such as pa sites and buildings you are advised to
contact the New Zealand Historic Places Trust, who will be able to tell you more regarding possible sites.
06/337654 March 2011 2
What is the current use of the site and surrounding area
Note If possible please provide photographs of the subject site with your application.
Assessment of environmental effects
An assessment of environmental effects is required with all resource consent applications. You will need to
consider actual and potential effects, and whether they will be minor or significant.
The detail of the assessment should reflect the magnitude of your proposal, (i.e. if you are constructing a
garage, your AEE will be simple, as opposed to an AEE for a motel complex).
If any effects as unknown it is recommended that you obtain professional advice to determine what the
effects will be.
What aspects of your proposal will affect
Others on your property and/or your neighbour (e.g. shading of their property, stormwater flow, increased noise)
Will these effects be significant or minor, and how can they be reduced
What effects will the proposal have on the wider community
Will these effects be significant or minor, and how can they be reduced
Maori culture (e.g. destroy or occupy site of significance to Maori)
Will these effects be significant or minor, and how can they be reduced
Any ecosystems (e.g. habitats for flora/fauna)
06/337654 March 2011 3
Will these effects be significant or minor, and how can they be reduced
The landscape and visual amenity of the environment (e.g. Buildings seen from the coast, vegetation
clearance/earthworks)
Will these effects be significant or minor, and how can they be reduced
Any archaeological sites, historic buildings, notable trees or any other area with a recognised value (e.g. recreation
or scientific area or site)
Will these effects be significant or minor, and how can they be reduced
Waterways in the area
Will these effects be significant or minor, and how can they be reduced
Any existing or potential natural hazards (e.g. flooding, slips)
Will these effects be significant or minor, and how can they be reduced
Will your proposal involve
The discharge of contaminants into the environment
Yes No
If yes, please describe, and a discharge consent will be required from the Northland Regional Council
06/337654 March 2011 4
Use of hazardous substances or hazardous installations
Yes No
If yes, please describe
Consultation with potentially affected parties
Where the District Plan provides and/or where council deems it necessary, you may be required to
undertake consultation with any parties who may be affected by your proposal, to obtain their written
approval consenting to your proposal. As a guideline, Council generally requires written consents from all
adjoining and adjacent landowners.
Have you discussed your proposal with people who may be affected by your proposal
Yes No
If yes, please list those people and the legal description of their property
Have any people given their written approval Yes No
If yes, these will need to be attached as part of your application
Other attachments
The following additional information is required with this form:
Advance fee
Covering letter
Plans
Planning maps
Statement of Iwi consultation
Certificate of title
Written approvals
Conservation assessment
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