Intermediate Site Alteration Permit

Property Owner's Name *

First

Last

Property Owner's Phone Number *

Property Owner's Email Address *

Property Roll Number

Example 23-01-000-000-00000-0000

Property Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Are you submitting on behalf of the property owner? *

Yes
No

Contractor Name *

Contractor Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Contractor Phone Number *

Contractor Email Address *

Is any part of the site alteration taking place in a Conservation authority regulated area? *

Yes
No

Please note that if the property is in an area regulated by a Conversation Authority, you will require additional permit approvals from the relevant Conversation Authority.

What is the zoning of the property? *

Indicate if unknown.

What is the current use of the property? *

Ex. Business, residential, farming purposes.

What is the size of the property in hectares? *

What is the size of the proposed site alteration work area in hectares? *

Provide a brief description of the Site Alteration project. *

Does any part of the site contain a watercourse? *

Yes
No

Is the proposed site alteration area within 30 metres of a watercourse? *

Yes
No

Is the site alteration area a minimum of 30 metres from all property boundaries and drainage swales? *

Yes
No

Are trees being removed as part of the Site Alteration project? *

Yes
No

Please note that if trees are being removed additional permits or approvals from the County of Wellington may be required.

Is the Site Alteration Permit associated with a building permit? *

Yes
No

Is the Site Alteration Permit associated with an approved Site Plan Control Agreement? *

Yes
No

Is this related to a By-Law Enforcement order? *

Yes
No

Please be advised that in accordance with Site Alteration By-law 2023-057 this Site Alteration Permit application is subject to double permit fees.

What is the source of fill for this project? *

Imported fill (imported from secondary location)
Native fill (fill that is being moved from one part of the subject property to another area on the same property)

What is the volume of Fill being imported from off-site in cubic metres? *

Has fill already been imported to the property? *

Yes
No

How much Fill has been imported to the site in cubic metres? *

Is fill being removed from the subject property as part of this permit? *

Yes
No

How much fill is being removed? *

Please note that if you are moving the Fill to be within the Township of Puslinch, a separate Site Alteration Permit is required for the destination site.

Upload site plan of the property showing the septic location. *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Will Fill be placed over the septic bed and tank area? *

Yes
No

Provide documentation to demonstrate that the Site Alteration will not cause an Adverse Effect. *

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Adverse effect shall have the same meaning as in the Environmental Protection Act, R.S.O. 1990, c. E.19 and means one or more of:

(i) Impairment of the quality of the natural environment for any use that can be made of it;

(ii) Injury or damage to Property or to plant or animal life;

(iii) Harm or material discomfort to any person;

(iv) An adverse effect on the health of any person;

(v) Impairment of the safety of any person;

(vi) Rendering any Property or plant or animal life unfit for human use;

(vii) Loss of enjoyment of normal use of Property; and

(viii) Interference with the normal conduct of business.

Provide documentation that the Fill complies with the parameters as set out in Section 3.8 of this By-law. *

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Section 3.8, Applicable Laws and Plans states that no person shall conduct, undertake, permit or carry out Site Alteration unless it complies with:

(i) This By-law;

(i) The Township Zoning By-law;

(ii) The Township Noise By-law;

(iii) The Township Property Standards By-law;

(iv) The Township Road Activity By-law;

(v) The Greenbelt Plan;

(vi) The requirements of a Conservation Authority with jurisdiction; and

(vii) All other applicable statutes, regulations, policies, and by-laws, including but not limited to Ontario Regulation 406/19, Regulation 347 and the Rules for Soil Management and Excess Soil Quality Standards.

Provide documentation pertaining to the collection and laboratory analysis of samples of the Fill. *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Provide documentation setting out the evaluation of the Fill sample results. *

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Provide documentation of the Quality Control/Quality Assurance Program. *

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Provide documentation of the Source Site Confirmation. *

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Provide a justification report prepared by a qualifed person demonstrating the need for the proposed volume of Fill to be imported to the site. *

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“Qualified Person” means a person who meets the qualifications as set out in Section 5 or 6 of Ontario Regulation 153/04.

Provide documentation that the proposed Site Alteration meets the definition of Beneficial Purpose. *

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Beneficial Purpose has the same meaning as in Ontario Regulation 406/19, and, for clarity, does not include deposit of Excess Soil as the primary use of the Site, but includes the following:

(i) backfill for an excavation carried out for the purposes of any form of development,

(ii) final grading carried out for the purposes of any form of development,

(iii) achieving the grade necessary for, any development, an undertaking related to infrastructure, landscaping, or another project governed by an instrument issued by a public body, or

(iv) the placement of fill to assist in the rehabilitation of the Site.

What is the largest change in grade associated with this application in metres? *

Upload the Intermediate Site Alteration Permit Checklist and Control Plan as per Schedule B, or aspects of the Control Plan as determined by the Designated Official. *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Do you plan to use site specific standards for soil quality for the Fill? *

Yes
No

If Site-specific standards for Soil quality acceptance have been developed using the MECP’s Beneficial Reuse Assessment Tool (BRAT), a copy of the BRAT model input and output and a signed statement by the Qualified Person that prepared the BRAT model must be submitted. *

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For more information regarding the Ontario Ministry of the Environment, Conservation and Parks Excess Soil Beneficial Reuse Assessment Tool (BRAT): https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fprod-environmental- registry.s3.amazonaws.com%2F2020- 12%2FBeneficial%2520Reuse%2520Assessment%2520Tool_BRAT%2520%2528Dated%2 52008%2520Dec%25202020%2529_0.xlsx&wdOrigin=BROWSELINK .

If Site-specific standards for Soil quality acceptance have been developed using a risk assessment pursuant to the requirements in the Rules for Soil Management and Excess Soil Quality Standards, a copy of the risk assessment and a signed statement by the Qualified Person that prepared the risk assessment model must be submitted. *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

For more information regarding the Ontario Ministry of the Environment, Conservation and Parks Excess Soil Beneficial Reuse Assessment Tool (BRAT): https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fprod-environmental- registry.s3.amazonaws.com%2F2020- 12%2FBeneficial%2520Reuse%2520Assessment%2520Tool_BRAT%2520%2528Dated%2 52008%2520Dec%25202020%2529_0.xlsx&wdOrigin=BROWSELINK .

Upload a Site Alteration and Fill Management Plan prepared by a Qualified Person *

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“Qualified Person” means a person who meets the qualifications as set out in Section 5 or 6 of Ontario Regulation 153/04.

Upload a document from the Owner and Qualified Person confirming that the Qualified Person will be present at the Property and be responsible for all activities associated with the Site Alteration at all times while activities are taking place. *

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This is required for the importation of Fill or the removal of Fill from the property.

Please provide any permits of approvals received from external agencies for this application to date (ex. Conservation Authority, Source Water Protection, County of Wellington).

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Upload an approved Haul Route Permit in accordance with the Township's Road Activity By-law. *

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This is required for the importation of Fill or the removal of Fill from the property.

Upload a schedule and timing of the Site Alteration activities. *

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No activities occur:

i. Between the hours of 5:00 p.m. and 8:30 a.m. Monday to Friday;

ii. Anytime on Saturday, Sunday or Statutory Holiday;

iii. During any period in which a wind warning has been issued by Environment Canada;

iv. During any weather conditions where the ability to mitigate Site Alteration activity impacts is severely compromised (e.g., heavy rain, etc.); and

v. During any situation where Site Alteration activities can unduly impact adjacent landowners (e.g., brush fires, floods, unsuitable road conditions, etc.).

Upload the Site Alteration Permit Owner Authorization Form if filling out the application on behalf of the property owner. *

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This form can be found on our Forms and Payments page, Puslinch.ca/forms.

I understand that staff will follow up regarding application fees. *

I have read the above and understand this requirement.

I agree that I have reviewed and understand the Township’s Site Alteration By-law 057-2023 and further that I will comply with all requirements set out in this by-law.

I understand that the owner shall be responsible for any prescribed fee as listed in the Township User Fees and Charges By-law.

I understand that the Owner shall be responsible for any third-party cost and recoveries if an external review is required as determined by the Designated Official.

I understand that all Intermediate Site Alteration Applications are subject to a staff review and comment period, which may form part of the Site Alteration Permit and may include conditions not described in this By-law.

I understand that the applicant’s may be required to submit additional documents.

I understand that the securities shall be provided to the Township in a form and amount to be determined in accordance with Schedule “C” to this By-law.

I understand that the Site Alteration Permit Application will be posted on the Township’s website upon submission to staff.

I understand that no person shall submit or cause or permit an application for a Permit to be submitted to the Township that is misleading or contains false information. Where it is revealed that the application for a Permit contained misleading or false information, the Designated Official may revoke the said Permit, and all work that was the subject of the revoked Permit shall immediately cease.

I understand that the Site Alteration Permit will expire one year after the date of issuance or as otherwise specified as a condition on the permit.

I understand that a Site Alteration Permit renewal may be requested if the only change from the initial application is the timeline and expiry date.

I understand that every Owner shall satisfy all conditions of the Permit, even if the Permit is expired.

I have read, understood and agree to the Terms and Conditions.

Signature *

Clear Signature