Mackenzie Valley Federal Areas Waters Regulations (SOR/93-303)

APPLICATION/LICENCE NO:

(amendment or renewal only)

• 1 NAME AND MAILING ADDRESS OF APPLICANT

  TELEPHONE: FAX:

• 2 ADDRESS OF HEAD OFFICE IN CANADA IF INCORPORATED

  TELEPHONE:FAX:

• 3 LOCATION OF UNDERTAKING (describe and attach a map, indicating watercourses and location of any proposed waste deposits)

  Latitude Longitude

• 4 DESCRIPTION OF UNDERTAKING (describe and attach plans)

• 5 TYPE OF UNDERTAKING

  • 1 Industrial

  • 2 Mining and milling

  • 3 Municipal

  • 4 Power

  • 5 Agriculture

  • 6 Conservation

  • 7 Recreation

  • 8 Miscellaneous (describe) 8.

• 6 WATER USE

  • To obtain water
  • To cross a watercourse
  • To modify the bed or bank of a watercourse
  • Flood control
  • To divert water
  • To alter the flow of, or store, water
  • Other (describe)

• 7 QUANTITY OF WATER INVOLVED (litres per second, litres per day or cubic metres per year, including both quantity to be used and quality to be returned to source)

• 8 WASTE DEPOSITED (quantity, quality, treatment and disposal)

• 9 OTHER PERSONS OR PROPERTIES AFFECTED BY THIS UNDERTAKING (give name, mailing address and location; attach list if necessary)

• 10 PREDICTED ENVIRONMENTAL IMPACTS OF UNDERTAKING AND PROPOSED MITIGATION

• 11 CONTRACTOR AND SUB-CONTRACTORS (names, addresses and functions)

• 12 STUDIES UNDERTAKEN TO DATE (attach list if necessary)

• 13 PROPOSED TIME SCHEDULE

  Start date Completion date

NAME  (Print)TITLE  (Print)SIGNATUREDATE

For Office Use Only

APPLICATION FEE         Amount: $ Receipt No.:

WATER USE DEPOSIT   Amount: $ Receipt No.: