IW-________ - ________
Ref # ________________
Subdivision # _________
OXFORD CONSERVATION COMMISSION / INLAND WETLANDS AGENCY
Date of Final Approved Map: __________________ Expiration date of Permit: ________________
Last Revised: _______________________________
Form OCCIWA 004 (Rev 2/19/2009 – 4/14/2010)
A. ______ APPLICATION permit for:
1) Approval for wetland/watercourse delineation and/or road layout.
2) Approval of site plan.
3) Activity in, impact to/disturbance of wetland, watercourse and/or setback area.
B. ______ NOTIFICATION to Planning & Zoning, Building, and/or Health Department that no Inland
Wetlands permit is required. Approval by IW Enforcement Officer.
C. ______ Permitted Operations & Uses under per CT State Statutes 22a-40.
Please Print Clearly or Type.
1) Applicants Name: _______________________________________________________ Phone: ____________________________
Address: ___________________________________ Zip: ________________ Email: ___________________________________
2) Property Owner (if not the applicant): _________________________________________ Phone: ____________________________
(If not owner, attach a letter of consent)
Address: _______________________________________________________________ Zip: ______________________________
3) Location of Site: _____________________________ Map: ____________ Block: ____________ Lot: __________ Unit: ______
Subdivision Name: _______________________________________________________
Is property subject to any conservation easements or preservation restrictions?________If yes please attach copy
s ent
4) Total Size and Dimension of Site (acres/ square feet): ______________________________________________________________
5) Proposed Use/Activity/Alteration: _____________________________________________________________________________
6) Total acreage/dimensions of wetlands/watercourse on site (acres/ square feet): __________________________________________
7) Wetlands Impacted (s/f): _______________________________ Upland Review Area Impacted (s/f): _______________________
8) Amount of material to be Removed (CY): ________________________ Deposited (CY): _________________________________
9) Type of heating source stored on site ( ie: gas, propane, etc.)___________________if yes show location of storage on map
10) Check whether any of the following apply:
[] A portion of the property affected by the decision of the Commission is located within five hundred (500) feet of the boundary of
an adjoining municipality.
[] A portion of the sewer or water drainage from the project site will flow through and significantly impact the sewage system
within the adjoining municipality.
[] Water run-off from the improved site will impact streets or other municipal or private property within the adjoining municipality.
[] Not Applicable.
If any of the above apply, the applicant is required to give written notice of his/her application to the Inland Wetlands Agency of
the adjoining municipality and submit a copy to OCCIWA. Notification must be by CERTIFIED MAIL/RETURN RECEIPT.
Please read: A fee must be paid at the time of submission. Application Fee: Checks payable to the Oxford Inland Wetlands Agency.
Some applications may require an additional State Fee due at time of submission. State Fee: Checks payable to the Town of Oxford. All
activities within a wetland and/or watercourse must be completed within 1 year of start.
The undersigned: 1) Understands that submission is complete only when all required fees, necessary information, supporting documents, maps,
etc. has been submitted. 2) Warrants that all information submitted herein, including all material and supporting documents are TRUE and
CORRECT to the best of my knowledge.
I understand that if any of the above statements are false, I may be subject to fines and/or penalties.
Signature of Applicant/Agent: _____________________________ ______________________________ ______________
Printed Signature Date
THIS SECTION TO BE COMPLETED BY AGENCY
Date application received / accepted: __________Fees received: _________Exemption Fee _____________Receipt #___________
Other material(s) received: _____________________________________________________________________________________
Disposition and Date:
