Application No:_________ 

Date Received:__________ 

Special Permit Application-MOSQUITO/BLACK FLY

NH Division of Pesticide Control 

PO Box 2042, Concord, NH 03302-2042 

(603) 271-3550 

3/08 

OFFICE USE ONLY 

Referred to:

 Approve Disapprove Signature Date 

Dept. Environ. Services ______ ______ _______________ ______ 

Dept. Res. & Eco. Dev. ______ ______ _______________ ______ 

Fish & Game Department ______ ______ _______________ ______ 

Dept. of Agriculture ______ ______ _______________ ______ 

Div. of Public Health ______ ______ _______________ ______ 

Div. of Pesticide Cont. ______ ______ _______________ ______ 

Type of Application Type of Material

Aerial _____ Insecticide _______________ 

Ground _____ Herbicide _________________ 

 Other______________________ 

Total Acreage __________________ ______________________ 

COMPLETED BY APPLICANT 

1. Name of applicant (individual, firm or agency):______________ _____________________________________________________________ 

Address: ____________________________________________________ 

City: __________________________ State: ____ Zip: ___________ 

Tel:_______________FAX:_______________License #:_____________ 

2. Name and address of party requesting application of pesticides 

(private, public, cooperative, or other): 

_____________________________________________________________ 

Address: ____________________________________________________ 

City: _________________________ State: ____ Zip: ____________ 

Tel:__________________________FAX:___________________________ 

3. Have there been any previous pesticide applications made to 

this site under special permit? Yes ____ No _____. If yes, 

specify special permit number, and year of issue and site(s) 

treated:______________________________________________________

______________________________________________________________ 

4. Reason or need for the proposed pesticide application: 

 a. Establish why pesticides application or treatment is 

necessary (submit survey results and other factors 

pertaining to basis for treatment proposal): 

 _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________ 

Permit App.: Mosquito - Page 1 of 5 
 b. Who determined the need for pesticide treatment? 

_____________________________________________________________

_____________________________________________________________ 

_____________________________________________________________

_____________________________________________________________ 

5. Description of Application: 

a. Target organism(s):____________________________________ ______________________________________________________

______________________________________________________ 

b. Application Method(s) (type of equipment, nozzles, etc.): 

(1) For Adulticide:____________________________________ ______________________________________________________

 ______________________________________________________ 

(2) For Larvicide:_____________________________________ 

______________________________________________________ 

______________________________________________________ 

(3) Other:_____________________________________________ 

______________________________________________________ 

______________________________________________________ 

c. Method of calibration and frequency for each type of 

application equipment (consult manufacturer and label of 

product as to specifications):______________________ 

_______________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________ 

d. On the lines provided below list the pesticide(s) to be 

used, the active ingredient of each one and each 

product’s EPA registration number [ATTACH COPY OF 

LABEL(s)]: 

 Product Name Active Ingredient EPA Registration # 

 _________________ ________________ __________________ 

 _________________ ________________ __________________ 

 _________________ ________________ __________________ 

 _________________ ________________ __________________

 _________________ ________________ __________________ 

 _________________ ________________ __________________ 

e. On the lines provided below list the pesticide(s) to be 

used, the rate of application and the total formulation 

amount to be applied: 

 Product Name Rate of Application Formulation Amount 

 ___________________ ___________________ ______________________ 

 ___________________ ___________________ ______________________

 ___________________ ___________________ ______________________

 ___________________ ___________________ ______________________

 ___________________ ___________________ ______________________ 

Permit App.: Mosquito - Page 2 of 5 
 f. Number of applications with approximate date(s) of 

pesticide application(s): 

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________ 

 g. Sequence of applications(s): 

(1) Number of application areas or blocks_______________ 

(2) Acreage of each_____________________________________ ____________________________________________________ 

 ____________________________________________________ 

 ____________________________________________________ 

(3) Total acreage_______________________________________ 

(4) Urban or rural applications_________________________ 

h. Environmental Consideration: 

(1) Explain any pesticide management techniques that 

will be incorporated into the pesticide management program 

specifically for environmental protection, such as mixing 

and filling sites, water resource protection, selection of 

pesticides that are considered low in persistence, 

etc:_______________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________ 

(2) If proposal entails the use of a pesticide with 

labeling that contains precautions related to environmental 

hazard, such as groundwater protection precautions, provide 

explanation justifying the use of these materials over 

those that are less hazardous to the 

environment:_______________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

_____________________________________________________ 

 

6. Map and description of treatment area: 

 a. Submit detailed map(s) showing the treatment area and any 

public water supplies within 1000 feet of the treatment area. The 

map should be at a scale of at least 1 inch equals 2000 feet 

(1:24000) or at least 1 centimeter equals 240 meters (1:25000). 

United States Geological Survey Topographic Maps are preferred at 

scales of 1:24000 or 1:25000 and must show: 

Permit App.: Mosquito - Page 3 of 5 
(1) Proposed treatment area(s); 

(a) Adulticiding route(s); 

(b) Larviciding surface waters to be treated 

(2) Adjacent area(s); 

(3) Land type/vegetative cover; 

(4) Surface waters within and adjacent to subject area(s); 

(5) location of nearby public water wells; and 

(6) Topographic Features. 

b. Description of treatment area: 

(1) Location and description of area_________________________ ______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________ 

(2) Specify all activities in the treatment area which might 

be affected by the pesticide application(s) including 

apiaries, cropping, ornamental nurseries, recreational 

areas, schools, etc._____________________________________ ______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________ 

c. Location of survey site(s)_________________________________ 

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________ 

7. Name and location of any public water supply wells relative to 

the treatment area(s) [append if necessary]____________________ 

_______________________________________________________________ 

_______________________________________________________________ 

_______________________________________________________________

_______________________________________________________________ 

8. Are the owners of all areas to be treated in agreement to the 

proposed treatment? Yes____ or No_____ 

a. If not, explain:__________________________________________ 

_____________________________________________________________ 

_____________________________________________________________

_____________________________________________________________ 

b. What mechanism will be employed to comply with those who 

do not want property treated?________________________________ 

_____________________________________________________________ 

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________ 

Permit App.: Mosquito - Page 4 of 5 
Permit App.: Mosquito - Page 5 of 5 

9. I certify that all information presented is accurate and true; 

cancellation of this application and withdrawal of license 

(Registration, Permit) may result from any falsification of the 

information presented. 

Applicant Signature_________________________________________ 

Print Name:_________________________________________________ 

Title:______________________________________________________ 

Representing:_______________________________________________ 

Date:_______________________________________________________ 

10. Town Official Signature_____________________________________ 

Print Name: ________________________________________________ 

Title:______________________________________________________ 

Date:_______________________________________________________ 

Because of possible adverse effects from repeated chemical pesticide applications, 

year after year, within public water supply watersheds, this agency recommends 

that you and your client pursue every means to include pesticide management 

practices that focus on water contamination prevention. It is highly recommended 

to incorporate and use methods to control future pesticide problems by methods 

other than chemical control into your pesticide management program. In general, 

we would not look favorably on annual or repeated chemical treatment in public 

water supply watersheds that do not consider pesticide management programs that 

demonstrate water contamination prevention methods. 

Enclosures: DETAILED MAPS - US Geological Survey - Current Map 

 SUPPORT DATA - Further description as required 

 LABEL(S) - Product(s) to be utilized 

NOTE: Application must be submitted with an original plus 

four (4) copies (5 sets total) of application, maps, labels and 

support information.

 (ALLOW 120 DAYS FOR PROCESSING)