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Date Rec'd. <br />TOWN OF GEORGETOWN Fee $ <br />By <br />WATERSHED PROTECTION DISTRICT FOR OFFICE USE <br />APPLICATION FOR EXEMPTION <br />The Public Works Director may determine upon written request that an activity or proposed <br />schedule of activities to be undertaken within the watershed protection district presents a de minimis <br />risk of pollution to or disruption of the town's water supply, watershed and/or waterworks and may, <br />thus, exempt or except such activity or activities from some or all of the normal application and/or <br />permit requirements under the town's watershed protection district regulations. The burden is on <br />the exemption applicant to supply sufficient information to demonstrate that the activity or activities <br />in question will present no more than a de minimis threat or risk to the town's water supply and/or <br />water supply system. In no event shall the installation or repair of a sewage disposal system be <br />deemed an exempt activity, and in all events an applicant must provide the Public Works Director <br />written notice of when and where any exempted activity is to occur. In the event an excepted or <br />exempted activity is not fully implemented or concluded in the manner as represented and <br />authorized, then the Public Works Director may order the cessation or correction of such activity in <br />accordance with the enforcement provisions contained in the town's watershed protection district <br />regulations. <br />Date: <br />Applicant: <br />Mailing address: <br />Telephone: (H) (Bus.) (Fax) <br />Name, mailing address and telephone number of landowner if different from applicant (application <br />must be accompanied by landowner's signed authorization): <br />Location/property description of activity site (provide street address, parcel no., subdivision lot and/or legal <br />description and size) (attach additional sheets ifnecessary): <br />Describe the activity, schedule of activities or structure(s) sought to be exempted from some or all <br />ofthe watershed protection district permitting process (attach additional sheets ifnecessary): <br />How close is the proposed activity/structure to the nearest primary stream or secondary intermittent <br />stream, lake, pond, wetland, watercourse, waterwork or drainage Swale: <br />I of 2 <br />