### MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY

W A TER BUREAU



# APPLICATION FOR PERMIT FOR CHEMICAL TREATMENT

TO CONTROL SWIMMER’S ITCH

Pur s uant to Par t 31, W a ter R e sour ces Pr otecti on, of the N a tur a l R e sour ces and Env i r onmental Pr otecti on Act, 1994 PA 451, as ame nded ( N R EPA) , and Par t 33, Aq uati c N u i s ance C o ntr o l

, of the

NREPA, appl i c at i on i s made by t he under s i g ned for a per m i t t o c h emi c al l y t r eat t h e w a t e r s des c r i b ed bel o w for

t h e c o nt r o l of s w im m e r’s itch.



# SECTION I. GENERAL INFORMATION

APPLIC AN T N A M E W A T E RB ODY NA ME (IF CA NA L / MA RINA , A L S O L I S T NA ME OF CA NA L / MA RINA )

M A ILIN G AD D R ESS C O U N T Y ( IES) T O W N ( S ) R A N G E( S) SEC T ION ( S )

C I T Y , ST AT E, ZIP C O D E TO TA L A R E A O F W A TE R B O D Y

T E LEPH ON E ( D AY T I M E ) FAC S IM ILE D I M E N S ION OF T R EAT M E N T AR EA ( F EET )

L E NGT H W I DT H DE P T H

LAKE ADDRESS (IF DIFFERENT FROM MAILING ADDRESS) AR EA T O BE T R EAT ED – M u l t i p l y l e ng th i n f eet by w i dth i n f e et and di v i de by 43,560

AC R ES



# SECTION II. TREATMENT INFORMATION

1. a. Trade name of chemical to be used _______________________________________________________________.

b. Amount of chem ical required ____________________________________________________________________.

c. Approximate date of app lication of chemical _________________________________________________________.

Note: Copper sulfate is the only permitted molluscicide for swimme r’s itch control. Due to copper toxicity to spawning

fish, treatments may be permitted one-time only after June 15, when most panfish have finished spawning in lake

shallows.

2

. Provide a treatment map on 81⁄2 " x 11" paper showing the lo cation of the treatment area, depth contours, inlets, outlets,

water level control structures, a scale in feet, and a north directional arrow. The treat ment map provided must be of

sufficient quality to allow the Michigan Department of Environm ental Quality (DEQ) to eval uate the proposed treatment or

the application may be returned. Certai n depth contour maps may be downloaded from http://www.michigan.gov/dnr . If a

map is not available, the applicant shoul d estimate the depth contours within the treatment area at 5-foot intervals.

3. If the proposed treatment area for swimmer’s itch control is 25 acres or more, provide the following information:

a. What is the snail species targeted fo r control? _________________________________. Refer to the brochure

“Swimmer’s Itch in Michigan” for the swimmer’s itch cycle, snail species involved, and snail habitat types.

b. What is the approximate density of this snail species within the tr eatment area? _____________snails/square foot.

This can be determined by placing a one-foot square frame at random points in treatment ar ea. Count snails present

in the frame, repeat several times at different lo cations in treatment area, and average the results.

c. How many medically documented cases of swimmer’s itch occurred during the last summer season?

____________


# 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, t he required fee is $200.00.

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

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

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

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

. Submit your check, completed applicat ion form, treatment map, and if necessary , authorization letter or contract to:

MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY

CASHIER’S OFFICE – WB – AQ

P.O. BOX 30657 FOR CASHIER'S USE ONLY : 37000-40509-9037-481003-00

EQP 2794 ( R ev . 02/06) AQ Pag e 1 of 2



# LANSING, MICHIGAN 48909-8157M I C H IGAN D EPAR T M EN T OF EN VIR O N M EN T A L QU ALIT Y

, W A T E R BU R EAU

APPLIC AT ION FOR PER M I T FOR C H E M I C A L T R EAT M E N T T O C O N T R O L SW IM M E R ’ S IT C H OR OT H E R N U I SAN C E AQU A T I C AN IM ALS

EQP 2794 ( R ev . 02/06) Pag e 2 of 2 

# SECTION IV. 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 Associat ion, Other Association

If the primary local contact person is not the applic ant, please provide the follo w i ng contact information:

N A M E OF PER SON R ESPON S IBLE FOR OR GAN I ZIN G T H E T R EAT M E N T N A M E OF ASSOC I AT ION , LAKE BOAR D

, T O W N SH IP BOAR D

, OR GAN I ZAT ION , ET C

.

M A ILIN G AD D R ESS C I T Y ST AT E ZIP C O D E T E LEPH ON E ( D AY T I M E ) FAC S IM ILE



# 2. If applicant is not the property ow ner, attach a letter or contract dem onstrating authorization for treatment.

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

provide information for five property ow ners 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 (pro vide copy of contract), may skip this item.

Name Address City State Zip Code Telephone

Number



# SECTION V. CERTIFICATION

I certify that the information provided is, to the best of my know ledge, 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 w i th label and permit requirements, take full responsibility for plann ing and

carrying out the permitted treatment, and agree to indemnify and save harmless the State of Michigan against any and all action s, claims, briefs, demands, damages, costs, loss, and ex penses in any manner resulting from or arising out of the permitted treatm ent.

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

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

PERMISSION T O APPLY PEST ICIDES, OR I REPRESENT A UNIT OF GOVERNMENT WIT H AUT H ORIT Y T O APPLY

PEST ICIDES. I ACCEPT RESPONSIBILIT Y F O R T H E PERMIT T H AT MAY BE ISSUED PURSUANT T O T H IS APPLICAT ION

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 chemic al treatment of their bottomland property:

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

Statutory Lake Board

Township/ S pecial A ssessment Dist rict

Applicant Signature: Date:

Name (print):