"Application for an Exemption to the Wellfield Protected Area Designation Order" - New Brunswick, Canada

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Application for an Exemption to the Wellfield Protected Area
Designation Order
Please note that an application must be filled out for each property that an exemption
is being applied for.
Name of Applicant: __________________
Wellfield: ____________________
Mailing Address: ____________________
Telephone Number
__________________________________
Home: _______________________
__________________________________
Business: _____________________
__________________________________
Fax: _________________________
Email Address: _________________
Owner of Property: ___________________
(If different from applicant)
Mailing Address: ____________________
Telephone Number
__________________________________
Home: _______________________
__________________________________
Business: _____________________
__________________________________
Fax: _________________________
Email Address: _________________
Property
PID: _________________________
Zone (A, B or C): ______________
Your Property Identification Number (PID) may be determined by referring to your
property tax bill or phoning Service New Brunswick (SNB) at 1-888-762-8600.
TYPE OF LAND USE
Please check one of the following that best describes your property’s land use:
Residential _____________
Commercial _____________
Industrial ______________
Agriculture ______________
Forestry _______________
Institutional ______________
Other (please specify) _________________
Application for an Exemption to the Wellfield Protected Area
Designation Order
Please note that an application must be filled out for each property that an exemption
is being applied for.
Name of Applicant: __________________
Wellfield: ____________________
Mailing Address: ____________________
Telephone Number
__________________________________
Home: _______________________
__________________________________
Business: _____________________
__________________________________
Fax: _________________________
Email Address: _________________
Owner of Property: ___________________
(If different from applicant)
Mailing Address: ____________________
Telephone Number
__________________________________
Home: _______________________
__________________________________
Business: _____________________
__________________________________
Fax: _________________________
Email Address: _________________
Property
PID: _________________________
Zone (A, B or C): ______________
Your Property Identification Number (PID) may be determined by referring to your
property tax bill or phoning Service New Brunswick (SNB) at 1-888-762-8600.
TYPE OF LAND USE
Please check one of the following that best describes your property’s land use:
Residential _____________
Commercial _____________
Industrial ______________
Agriculture ______________
Forestry _______________
Institutional ______________
Other (please specify) _________________
DESCRIPTION OF LAND USE
Briefly describe the use of the property and whether the use is existing or proposed (i.e.
existing service station, existing dry cleaning operation, new sawmill, etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
DESCRIPTION OF CHEMICAL USE/STORAGE
Provide a list of chemicals or other substances (including petroleum products) that will be
used or stored at the site with typical storage quantities (use additional paper if required).
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Note: You must include the age of all petroleum storage tanks on the property (this
can be found on a metal tag attached to the oil tank) and the installation date if
known.
HAVE YOU PREVIOUSLY REQUESTED AN EXEMPTION FROM THE
MINISTER?
Yes
No
If so, please quote the file number: _________________________
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO
THE BEST OF MY KNOWLEDGE
Applicant Signature: _________________________
Date: ___________________
File Number: _______________________________
(for NBDENV use only)
Once your application is completed, please mail it c/o the Wellfield Protection Program
at the address below:
Department of the Environment
Attn: Sustainable Planning Branch
P.O. Box 6000
Fredericton, NB
E3B 5H1
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