Site Alteration Assessment Inquiry Form

Prior to receiving a Site Alteration Permit, the Site Alteration Assessment Inquiry Form must be completed.

Prior to completing this form, please complete the Haul Route Permit form.

Before completing the form, please read the By-law 2023-057 Site Alteration By-law. Any questions should be directed to the By-law Department.

After this form is submitted, staff will review the information and let you know which permit type is required for your project.

A Site Alteration Permit is required whenever there is any alteration to the existing Grade of land through the removal, placement, movement, or relocation of Fill.

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

OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvince

Postal Code

Are you submitting on behalf of the property owner? *

• Yes
• No

Contractor Name *

Contractor Address *

Address Line 1

Address Line 2

City

AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvince

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? *

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)

Describe the material of the fill. *

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? *

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

Upload any preliminary drawings or documents

Click or drag files to this area to upload. You can upload up to 5 files.

I understand that this is an assessment form for a Site Alteration Permit and is not considered an application. As a result of completing this form staff will advise which Site Alteration Permit Application type and supporting documents are to be submitted.

• I have read the above and understand this requirement.

Signature *

Clear Signature

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