Special Permit Application- AQUATIC NH Division of Pesticide Control PO Box 2042, Concord, NH 03302-2042 (603) 271-3550 4/08 OFFICE USE ONLY Referred to:

Permit App.: Aquatic - Page 1 of 6

TREATMENT AREA DESCRIPTION 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 __________________ ______________________ APPLICANT INFORMATION Application No:_________ Date Received:__________

1. Name of applicant (individual, firm or agency):______________
_____________________________________________________________ Address: ____________________________________________________ City: __________________________ State: ____ Zip: ___________ Tel:_______________FAX:_______________License #:_____________ 2. If the applicant is not a licensed applicator, provide name, address and license number of licensed pesticide applicator who will undertake project: _________________________________
_____________________________________________________________ _____________________________________________________________ 3. Name and address of party requesting application of pesticides (private, public, cooperative, or other)
_____________________________________________________________ Address: ____________________________________________________ City: _________________________ State: ____ Zip: ____________ Tel:__________________________FAX:___________________________ 4. Has the licensed applicator received any previous special permits for this site? Yes ____ No _____. If yes, specify special permit number and year of issue for the most recent special permit:______________________________________________Permit App.: Aquatic - Page 2 of 6 5. Description and map of treatment area(s): a. Description and location(s) of area(s) to be treated:

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_________________________________________________________ _________________________________________________________ (1) Length along shoreline__________________________FT (2) Width outward from shoreline____________________FT (3) Average depth___________________________________FT (4) Surface area in acres_________acre feet___________ (5) Type of bottom____________________________________ (6) Are any parts of the proposed treatment area places where boats congregate for recreational usage such as boat rafting, water skiing, riding of personal watercraft or similar activities? Yes______ No______ If yes, indicate the location(s) of the nearest public and private boat ramps. a. Attach a map (scale of 1” = 800-1000 feet) showing the location of the body of water and areas to be treated in relation to its total area. Indicate: (1) Location of riparian owners, abutters, and others affected by the treatment; (2) Location of all inlet and outlet steams; (3) Location of all bathing areas; (4) Location of “base of operations” if treatment is approved; (5) Location of sampling sites; (6) Location of depth findings; (7) Location of public and private water wells and surface water supplies (include intakes) where water is used for domestic purposes. Include identification of downstream uses. 6. State reason and need for the proposed treatment:

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_______________________________________________________________ _______________________________________________________________ 7. Can water level be controlled?_________________________________ If so, how?____________________________________________________

_______________________________________________________________ _______________________________________________________________Permit App.: Aquatic - Page 3 of 6 8. Names of predominant game fish species known to be present:

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_______________________________________________________________ _______________________________________________________________ 9. Names and addresses of all abutters: [ATTACH LIST] 10. Names and addresses of all persons utilizing waters for domestic purposes: [ATTACH LIST] 11. Water use by abutters and those not contiguous to the treatment area: a. Name and location of any public water supply wells relative to treatment area (append if necessary)_________________________

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________________________________________________________________ ________________________________________________________________ b. Name and location of any private water supply intakes and wells relative to treatment area (append if necessary)__________

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________________________________________________________________ ________________________________________________________________ c. Describe bathing use, including locations relative to treatment area__________________________________________________

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________________________________________________________________ ________________________________________________________________ d. Describe livestock watering, agricultural uses; include locations relative to treatment areas___________________________

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________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 12. Use of outlet waters a. Name and location of nearest source of public water supply

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________________________________________________________________ ________________________________________________________________ b. Names and locations of nearest sources of private water supply along outlet stream______________________________________

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________________________________________________________________ ________________________________________________________________ c. Location of nearest point downstream where waters are used for bathing_____________________________________________________

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________________________________________________________________ ________________________________________________________________d. Location of nearest point downstream where waters are used for watering livestock, agriculture, etc._______________________

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________________________________________________________________ ________________________________________________________________ DESCRIPTION OF APPLICATION 13. Description of pesticide application: (1) Target organism(s)__________________________________________

________________________________________________________________ ________________________________________________________________ (2) Method of treatment_________________________________________
________________________________________________________________ (3) Pesticide to be used (ATTACH COPY OF LABEL) (a) Name of product________________________________________ (b) Rate of application____________________________________ (c) Amount of formulation to be applied____________________ (4) Planned maximum concentration of the chemical to be used in the area to be treated expressed in parts per million, in terms of its chemical formula or radical, and state such formula or radical__________________________________________ (5) Date of application of pesticide____________________________ (6) Sequence of application: (a) Number of blocks or acres______________________________ (b) Acreage of each________________________________________
____________________________________________________________ 14. Name of laboratory conducting sampling:__________________________
________________________________________________________________ (1) Address: Street: _____________________City:__________________ State: _______________________________ Zip: ________________ Telephone Number:____________________________________________ Lab spokesperson taking samples:_____________________________
_____________________________________________________________ 15. Are you prepared to assure the permitting official that other riparian owners will restrict their usage of water during and following the chemical application in accordance with any instructions on the pesticide label and/or advice of such permit issuing official? _________ a. Do other riparian owners, both in the vicinity of the treatment area and along the outlet stream, who may have to temporarily restrict their usage of water, approve of the proposed application?____________________________________________

_________________________________________________________________ _________________________________________________________________ Permit App.: Aquatic - Page 4 of 6Permit App.: Aquatic - Page 5 of 6 16. If approval as specified under 15a. above is not obtained, provide: a. A statement as to reason approval was not obtained:

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_________________________________________________________________ _________________________________________________________________ b. A description of the nature of and reason for any objections, where such information is known to the applicant:

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_________________________________________________________________ _________________________________________________________________ b. Copies of any written objections that might have been directed to the applicant shall be attached to this “Special Permit Application.” 17. Names and addresses of those objecting to the treatment. [ATTACH LIST] 18. a. What notification to abutters and others affected by treatment, as to your proposal, have been given?

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_________________________________________________________________ _________________________________________________________________ b. What notification will be given to abutters, those on the outflow (down) side of the treatment area, and all others affected by the treatment, including those entering the treatment area via watercraft, prior to treatment?

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_________________________________________________________________ _________________________________________________________________ c. How will the treatment area be posted? ______________________

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_________________________________________________________________ _________________________________________________________________ ATTACH A COPY OF THE NOTICES, NEWS RELEASES AND LETTERS ALONG WITH DATE NOTICE WAS GIVENAPPLICATION CERTIFICATION 19. The issuance of any permit is based on the assumed accuracy of all statements presented by the applicant in this application. Damage resulting from the inaccuracy of any computations, improper application of the chemical, or legal responsibility for the representations made in obtaining approvals or releases or failure to obtain approvals or releases from other riparian owners likely to be affected is the sole responsibility of the applicant. Do you agree to the acceptance of this condition as a prerequisite to the issuance of a permit?___________________ 20. Applicant Signature_________________________________________ Print Name__________________________________________________ Representing:_______________________________________________ Date:_______________________________________________________ 21. Signature of Spokesperson/Contractor________________________ Print Name: ________________________________________________ Representiong:______________________________________________ Date:_______________________________________________________ NOTE: An original signed application must be submitted plus four (4)copies including all maps and supporting information (5 sets total) Enclosures: DETAILED MAPS - US Geological Survey - Current Map SUPPORT DATA/LISTS - Further description as required LABEL(S) - Product(s) to be utilized (ALLOW 120 DAYS FOR PROCESSING)

Permit App.: Aquatic - Page 6 of 6