Application to Modify an Inland Wetlands License

Application to Modify an Inland Wetlands License
Additional information regarding modifications to approved wetlands applications can be found in Section 11.8 of the Inland Wetlands and Watercourses Regulations, The Agency has the authority to approve modifications withoutsubmittal of a new application. However, if the Agency determines that the proposed modification is a significant or substantial alteration of the application as approved, they will require the filing of a new application. Review of the application will be subject to the requirements in the regulations and may be subject to a public hearing.
- Prior to completing the application, be sure to have the required information and documents ready.
- Make sure that required documents are saved in pdf form and appropriately named. For example: "SitePlan," "Stormwater Management Plan," "Alternatives Analysis," "Wetlands Functions and Values Report," etc.
- Use care when entering numbers into the form. The software includes an up/down arrow symbol in the right corner of each number field. This is intended to make completion of forms on a mobile device user friendly,but can inadvertently result in changing the number you have typed if you move your cursor within the field. Be sure to double-check your numbers before moving on as the form will automatically use this informationto calculate certain information, such as the net change to wetlands, watercourses, and open water bodies.
- Please call the Department of Planning and Development at 860.429.3330 or email us at planzonedept@mansfieldct.org with any questions on how to complete the form.
Who is completing the application form?*
- The applicant is the person/organization that is formally requesting an Inland Wetlands License for the activities described in this application. The applicant may be the property owner of record or another party, such as a prospective purchaser or developer.
- An agent for the applicant is an attorney, engineer, soil scientist or other professional/technical consultant that is retained by the applicant to assist with the application.
Applicant Information
Is the Applicant the Property Owner?*
Applicant Full Name*

First NameLast Name
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Email*
example@example.com
Property Owner Information
Property Owner Full Name

First NameLast Name
Property Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Property Owner Email
example@example.com
Agent Information
Have any agents been authorized to represent the applicant regarding this application? *
Please provide the contact info for each person that may be directly contacted regarding the application.*
Property Information
Address/Location of Subject Property*
Please use Mansfield's GIS website for the questions below.
Assessor Parcel Identification Number*
Total Land Area of Subject Parcel (Acres)*
Is some or all of the property located within the flood zone?*
What zone is the property located in? (If multiple, list each)*
Does the most recent CTDEEP Natural Diversity Database Map identify an area of concern on the subject property?*
Is the subject property located within a designated Aquifer Protection Area?*
Please use the USGS Quadrangle and Sub-Regional Drainage Basin map for the questions below.
Coventry (40)Spring Hill (41)Columbia (55)Willimantic (56)
310032003204320632073208
Project Information - Proposed Modifcations

In completing this section of the application, the applicant must provide sufficient information to determine whether the modification complies with all applicable wetland regulations.
Please provide the project file number (if known)
Describe any proposed change(s) and the reason/justification for the proposed change(s):*
What is the difference (in feet) that the proposed activity will be from the edge of wetlands/watercourses?*
Does the area of proposed activity drain towards the wetlands?*
Is there a difference from the approved permit in the type of equipment and machinery will be used?*
If so, please explain.
Upland Review Area Disturbance
Briefly describe how the activities you propose within the upland review area differ from the original application, if applicable.*
Quantify the difference in the area of disturbance within 150 feet of wetlands/watercourses (square feet):*
Quantify the difference in volume of materials being extracted within 150 feet of wetlands/watercourses (cubic yards):*
Quantify the difference in volume of materials being deposited within 150 feet of wetlands/watercourses (cubic yards):*
Quantify the difference in volume of materials being dispersed within 150 feet of wetlands/watercourses (cubic yards):*
Wetlands Disturbance
Were there any activities in the wetlands or watercourses in the original application?*
Will there be any change in disturbance in the wetlands/water body?*
Briefly describe how the activities you propose within the wetlands differ from the original application, if applicable.
Wetlands Protection Measures
Do the Erosion and Sedimentation controls differ from the original plan?*
Will the proposed modification of activities impact the wetlands/watercourses of an adjoining property?*
Are there any potential impacts to neighboring municipalities caused by the proposed modifications?*
Willimantic Reservoir Watershed Notification
The Willimantic Reservoir Public Drinking Water Supply Watershed encompasses much of the eastern half of Mansfield. To determine if your project is located within the Willimantic Reservoir Public Drinking Supply Watershed, please review this map.
Is your project located within the Willimantic Reservoir public drinking supply watershed?*
Submissions - Required Maps and Documentation
In addition to completion of this form and payment of the application fee, the following items are required for an application to be considered complete. Please contact the Department of Planning and Development at planzonedept@mansfieldct.org to submit electronic pdf copies of these documents. Original signed and sealed copies of all submissions must be provided to the office in physical format, and additional copies may be required for certain documents as specified. All documents shall be dated, including revision dates. Additional information regarding wetlands mapping and other submission requirements can be found in Section 7 of the Mansfield Inland Wetlands and Watercourses Regulations.
1. Applicants must complete Part 2 of the Statewide Inland Wetlands and Watercourses Activity Reporting Form. For question six you will need to use the USGS Quadrangle and Sub-Regional Drainage Basin map. The completed form must submitted with your application.
2. Site Plan. In order for the Agency to effectively evaluate your request for a modification, a site plan showing the approved site plan and the proposed modifications in relation to wetlands/watercourses is required. (See Section 7.4 of the Inland Wetlands and Watercourses Regulations for specific information that must be included on the map). If possible, the
  scale of the map should be 1"=40'. At minimum, the plan must include:
  - Applicant’s name Date and revision date, if applicable.
  - North arrow and scale of map.
  - Abutting road with road name shown on it.
  - Property lines --if a large property, at least those lines within 200’ of the proposed work.
  - Wetland and watercourse locations (including those off your property) within 150’ of your proposal--draw a line showing the part of the project that is the closest distance to wetlands and indicate distance in feet.
  - Existing buildings, driveways, well, septic and physical features of the original application and the proposed modifications
  - Proposed modifications of work in detail, including all areas of construction, grading/regrading, excavation, filling. Include stockpiling and staging area locations if applicable. The exact location must be shown of all areas that will be disturbed.
  - Show roof and footing drains by drawing locations.
  - Show location of Erosion & Sedimentation controls (i.e. silt fence or straw bale protections) together with any other measures that will protect the wetland/watercourse areas.
Application Fee
A non-refundable application fee of $110 is required pursuant to Section 122-2 of the Mansfield Code of Ordinances. This fee includes a $60 land use fee required by the State of Connecticut. Application Fees are accepted as follows:
- Check. A check payable to the Town of Mansfield can be paid in person at the Department of Planning and Development; left in the drop box at the eastern entrance to Town Hall in an envelope addressed to the Department of Planning and Development; or mailed to: Department of Planning and Development, 4 South Eagleville Road, Mansfield, CT 06268-2599
- Credit Card. Credit card payments are accepted in person in the Department of Planning and Development or over the telephone at 860.429.3330 during regular business hours.
- Cash. Cash in the amount due can be paid in person at the Department of Planning and Development.
Certification Statement
In signing this document, I hereby certify that I am, or have been authorized as an agent to act on the behalf of, the Applicant identified in this application.

I understand that no application submitted by an agent will be considered complete until the Applicant completes and submits the Applicant Certification Statement.

I understand that no application submitted by an Applicant will be considered completed until the Property Owner of record, if different, completes and submits the Property Owner Certification Statement.
Signature*

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Application to Modify an Inland Wetlands License

Applicant Information

Property Owner Information

Agent Information

Property Information

Project Information - Proposed Modifcations

Upland Review Area Disturbance

Wetlands Disturbance

Wetlands Protection Measures

Willimantic Reservoir Watershed Notification

Submissions - Required Maps and Documentation

Application Fee

Certification Statement