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Township of West Lincoln

Site Alteration - Application for Less than 500m³/Year of Fill

Date

Owner Name (First and Last)

Municipal Address

Primary Phone Number

E-mail Address

Do you propose to add fill to the property?

Do you propose to alter the grading of the property?

Do you propose to remove soil from the property?

Do you propose to construct a retaining wall(s)?

Is there a registered flood and/or fill line on the property?

Is there an environmentally sensitive area (ESA) on this property?

Please describe the nature of the proposed works.

Sketch or Plan of Proposed Works

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The undersigned certifies to the Township of West Lincoln that any and all Fill used in completing the Site Alteration contains no contaminants within the meaning of the Environmental Protection act, R.S.O. 1990, c.E. 19. The undersigned hereby releases and agrees to indemnify and save harmless the Township, its employees, representivies, agents, and contractors, from and against all claims, demands, damages, causes of action, costs, expenses and other liabilities of any nature, which may arise in the event that the Fill is determined to contain contaminants.

The undersigned also agrees that the total costs of all works will be entirely the responsibility of the Owner.

Signature of Owner/Applicant

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Township of West Lincoln