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CONSERVATION
COMMISSION
Lawrence
Memorial Hall
2 Jabish Street, Post Office Box 670
Belchertown, Massachusetts 01007-0670
(413)
323-0405
COMBINATION OF FILING
Under
the
MASSACHUSETTS WETLANDS
PROTECTION ACT
And
BELCHERTOWN WETLAND BYLAW
The
Applicant hereby requests that the Belchertown Conservation Commission use the
state documents as the basis for the application under the Belchertown Wetlands
Bylaw and combine the hearing for the state and local requirements. The applicant understands that the
Conservation Commission may require additional information to be submitted
under the Belchertown Wetlands Bylaw.
Name
of Applicant _________________________________________________________________
Location___________________________________________________________________________
Map_________________________________Lot
Number __________________________________
Request
for Determination________ Notice of Intent____________ ANRAD____________
RESOURCE AREA: Check
appropriate area within which work is proposed:
STATE JURISDICTION LOCAL
JURISDICTION
____ Bank _______ Isolated Wetland
____ Land Under Water _______ Ephemeral Pool
____ Bordering Vegetated Wetlands _______ Pond Less Than 10,000ft.2
____
Isolated
Land Subject to Flooding
_____ Buffer
_____ Riverfront
Area
_____ Bordering Lands Subject to Flooding
FEES: State Fee________________ Local
Fee____________________
Signature
of Applicant _________________________________________________________
Date________________________________