EQP 2790 (Rev. 02/06) AQ Page 1 of 3 

MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY 

WATER BUREAU 

APPLICATION FOR PERMIT OR CERTIFICATE OF COVERAGE 

FOR CHEMICAL TREATMENT TO CONTROL 

NUISANCE AQUATIC PLANT AND/OR ALGAE GROWTH 

Pursuant to Part 31, Water Resources Protection, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended (NREPA), and Part 33, Aquatic Nuisance Control, of the 

NREPA, application is made by the undersigned for a permit to chemically treat the waters described below for the control of nuisance aquatic plant and/or algae growth. 

SECTION I. GENERAL INFORMATION 

APPLICANT INFORMATION WATERBODY INFORMATION 

 APPLICANT NAME WATERBODY NAME (IF CANAL/MARINA, ALSO LIST NAME OF CANAL/MARINA) 

 MAILING ADDRESS COUNTY(IES) 

 CITY, STATE, ZIP CODE TOWNSHIP NAME(S) TOWN(S) RANGE(S) SECTION(S) 

 TELEPHONE (DAYTIME) FACSIMILE 

 

OTHER INFORMATION FOR PRECISE LOCATION (E.G., NEARBY CROSSROADS) 

LAKE ADDRESS (IF DIFFERENT FROM MAILING ADDRESS) SURFACE AREA OF ENTIRE WATERBODY (ACRES) 

SECTION II. TREATMENT AREA

1. DIMENSION OF TOTAL TREATMENT AREA 

 Length feet Width feet Average depth of treatment area feet 

2. TOTAL SURFACE ACRES PROPOSED FOR TREATMENT ACRES (1 acre = 43,560 square feet) 

 Multiply length in feet by width in feet and divide by 43,560. 

SECTION III. REQUIRED FEES

Fees are based on the size of the proposed treatment area. ALL FEES ARE NON-REFUNDABLE. Check appropriate box: 

 For treatment of areas less than 1⁄2 acre, the required fee is $75.00. 

 For treatment of areas of 1⁄2 acre or more but less than 5 acres, the required fee is $200.00. 

 For treatment of areas of 5 acres or more but less than 20 acres, the required fee is $400.00. 

 For treatment of areas of 20 acres or more but less than 100 acres, the required fee is $800.00. 

 For treatment of areas of 100 acres or more, the required fee is $1,500.00. 

 Certificate of Coverage under General Permit No. ___________________ – $75.00 (all current General Permits and the 

list of pre-approved waterbodies may be obtained by visiting http://www.michigan.gov/deq or by calling 

517-241-7734). 

Payment must be made in full or your application will be returned. Checks should be payable to: STATE OF MICHIGAN. 

 Submit your check, completed application form, and if necessary, a treatment map and authorization letter or contract to: 

 MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY 

 CASHIER’S OFFICE – WB – AQ 

 P.O. BOX 30657 

 LANSING, MICHIGAN 48909-8157 

FOR CASHIER'S USE ONLY: 37000-40509-9037-481003-00
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALIITY, WATER BUREAU 

APPLICATION FOR PERMIT OR CERTIFICATE OF COVERAGE FOR CHEMICAL TREATMENT TO CONTROL NUISANCE AQUATIC PLANT AND/OR ALGAE GROWTH 

EQP 2790 (Rev. 02/06) AQ Page 2 of 3 

SECTION IV. TREATMENT INFORMATION (Use product labels to determine amount of chemical to be used on each species.) 

Applicants seeking a Certificate of Coverage may skip the table (see below). 

NAME OF EACH COMMERCIAL PRODUCT 

OR CHEMICAL REQUESTED 

LIQUID OR 

GRANULAR 

TARGET PLANT(S) AND/OR 

ALGAE (Be Specific) 

DIMENSION IN FEET OR 

AREA IN ACRES OF 

TREATMENT 

AMOUNT OF EACH 

CHEMICAL 

REQUESTED 

APPROXIMATE 

DATE(S) OF 

APPLICATION 

 L G 

 L G 

 L G 

 L G 

 L G 

 L G 

 L G

 L G 

 L G 

 Certificate of Coverage applicants – request the option to use any of the chemicals approved under a General Permit. 

The waterbody must qualify under an existing General Permit for aquatic nuisance control activities. Each General Permit 

lists the approved chemicals, application rates, and permit conditions. Check box if appropriate. 

 

SECTION V. TREATMENT MAP 

Provide a proposed treatment map for the waterbody to be treated on 8 1⁄2” x 11” paper. The map must show an accurate 

representation of the waterbody shape, and should include: (1) depth contours1

; (2) treatment area by chemical type; 

(3) known wetlands within or adjacent to the treatment area; (4) water level control structures; (5) inlets and outlets; and (6) 

private and public access sites and parks. The legend should include the lake name, county, waterbody size, proposed 

treatment area size, a scale in feet, a "North" directional arrow, and a key to the chemical products used in the treated 

areas. The map must include all information and be of sufficient quality to allow the Michigan Department of Environmental 

Quality (MDEQ) to evaluate the proposed treatment or the application may be returned. 

1 Certain depth contour maps may be downloaded from http://www.michigan.gov/dnr. If a map is not available, the 

applicant should estimate the depth contours within the treatment area at 5-foot intervals. 

 Certificate of Coverage applicants – treatment map has previously been submitted in this applicant’s name, and no 

change from the previous treatment is proposed. Therefore, a new treatment map is not required for a Certificate of 

Coverage. Check box if appropriate. 

SECTION VI. SAFETY AND PUBLIC HEALTH INFORMATION 

1. The residential drinking water supply within the proposed treatment area is: Municipal Private Both 

 NOTE: Granular endothall and granular 2,4-D products may not be applied within 75 feet of ANY well OR within 250 feet of 

wells less than 30 feet deep. Isolation distances are measured from the well location. 

2. Does the lake or pond being treated have an outlet that flows any time during the year? Yes No 

 If the answer is yes, please provide the following information: 

a. Is there a water level control structure? Yes No 

If yes, indicate type of water level control structure (e.g., dam, high-water overflow): 

b. What is the outlet flow? Intermittent Continuous 
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALIITY, WATER BUREAU 

APPLICATION FOR PERMIT OR CERTIFICATE OF COVERAGE FOR CHEMICAL TREATMENT TO CONTROL NUISANCE AQUATIC PLANT AND/OR ALGAE GROWTH 

EQP 2790 (Rev. 02/06) AQ Page 3 of 3 

SECTION VII. RESPONSIBILITY FOR UNDERTAKING TREATMENT 

1. Treatment by: Individual Property Owner Statutory Lake Board (PA 451 of 1994, as amended) 

 Group of Individual Property Owners Township (PA 188 of 1954, as amended) 

 Lake Association, Condo Association, Other: 

 Homeowners Association, Other Association 

 

If the primary contact person is not the applicant, please provide the following contact information:

NAME OF PERSON RESPONSIBLE FOR ORGANIZING THE TREATMENT NAME OF ASSOCIATION, LAKE BOARD, TOWNSHIP BOARD, ORGANIZATION, ETC. 

MAILING ADDRESS CITY STATE ZIP CODE TELEPHONE (DAYTIME) FACSIMILE 

2. If applicant is not the property owner, attach a letter or contract demonstrating authorization for treatment. 

3. If more than one property is involved, provide contact information for all property owners. For five or more properties, 

provide information for five property owners with knowledge of the treatment. Note: Applicants who are commercial 

applicators with a current Emergency Notification Procedure (ENP) on file with the MDEQ, or riparian property owners who 

have hired a commercial applicator with an ENP (provide copy of contract), may skip this item. 

Name Address City State Zip Code Telephone 

Number

SECTION VIII. CERTIFICATION 

I certify that the information provided is, to the best of my knowledge, correct. It is understood that a permit, if granted, can be 

revoked by the MDEQ, as specified in R 323.3109 promulgated pursuant to Part 33 of Act 451 of 1994, as amended. If a permit is

granted, I agree to use materials strictly in accordance with label and permit requirements, take full responsibility for planning and 

carrying out the permitted treatment, and agree to indemnify and save harmless the State of Michigan against any and all actions, 

claims, briefs, demands, damages, costs, loss, and expenses in any manner resulting from or arising out of the permitted treatment. 

I agree to submit the post-treatment data required. I HEREBY CERTIFY THAT THE PROPERTIES TO BE TREATED ARE 

EITHER UNDER MY LEGAL CONTROL AND/OR UNDER THE LEGAL CONTROL OF PARTIES WHO HAVE GRANTED ME 

PERMISSION TO APPLY PESTICIDES, OR I REPRESENT A UNIT OF GOVERNMENT WITH AUTHORITY TO APPLY 

PESTICIDES. I ACCEPT RESPONSIBILITY FOR THE PERMIT THAT MAY BE ISSUED PURSUANT TO THIS APPLICATION 

AND UNDERSTAND THAT VIOLATIONS ARE SUBJECT TO PENALTIES UNDER PART 33 OF ACT 451 OF 1994, AS 

AMENDED INCLUDING IMPRISONMENT AND FINES UP TO $25,000. 

Prior to carrying out the permitted chemical treatment, I will have obtained written permission from all of the property owners

within the treatment area, for the chemical treatment of their bottomland property: 

 Yes (including property owner treating own property) No - check basis for authority: 

 Statutory Lake Board 

 Township/Special Assessment District 

 

Applicant Signature: Date: 

 

Name (print):