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: 

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________ 

(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: 

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________ 

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: 

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________ 

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)_________________________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

b. Name and location of any private water supply intakes and 

wells relative to treatment area (append if necessary)__________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

c. Describe bathing use, including locations relative to 

treatment area__________________________________________________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

d. Describe livestock watering, agricultural uses; include 

locations relative to treatment areas___________________________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

________________________________________________________________ 

12. Use of outlet waters 

a. Name and location of nearest source of public water supply 

________________________________________________________________

________________________________________________________________ 

________________________________________________________________

________________________________________________________________ 

b. Names and locations of nearest sources of private water 

supply along outlet stream______________________________________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

c. Location of nearest point downstream where waters are used 

for bathing_____________________________________________________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________ 
d. Location of nearest point downstream where waters are used 

for watering livestock, agriculture, etc._______________________ 

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

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 6 
Permit 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: 

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________ 

b. A description of the nature of and reason for any objections, 

where such information is known to the applicant: 

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________ 

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? 

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________ 

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? 

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________ 

c. How will the treatment area be posted? ______________________ 

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________ 

ATTACH A COPY OF THE NOTICES, NEWS RELEASES AND LETTERS ALONG 

WITH DATE NOTICE WAS GIVEN
APPLICATION 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