Conservation Commission - 146 (06/10/2021)

rev. 1/2018 e 
79 Elm Street • Hartford, CT 06106-5127  
 
  www.ct.gov/deep 
         Affirmative Action/Equal Opportunity Employer 
 
 
 
 
 
 
 
 
 
 
 
Statewide Inland Wetlands & Watercourses Activity Reporting Form 
 
Please complete and mail this form in accordance with the instructions on pages 2 and 3 to: 
DEEP Land & Water Resources Division, Inland Wetlands Management Program, 79 Elm Street, 3rd Floor, Hartford, CT 06106 
Incomplete or incomprehensible forms will be mailed back to the municipal inland wetlands agency. 
   
PART I:   Must Be Completed By The Inland Wetlands Agency 
 
1. 
DATE ACTION WAS TAKEN:       year:   Click Here for Year 
  month:   Click Here for Month 
 
2. 
CHOOSE ACTION TAKEN (see instructions for codes):    Click Here to Choose a Code                             
 
3.  WAS A PUBLIC HEARING HELD (check one)?     yes  
       no  
 
 
4. 
NAME OF AGENCY OFFICIAL VERIFYING AND COMPLETING THIS FORM: 
 
 
(type name)               (signature)    ______________________________________ 
 
 
PART II:  To Be Completed By The Inland Wetlands Agency Or The Applicant 
 
5. 
TOWN IN WHICH THE ACTION IS OCCURRING (type name):    Waterford 
 
 
does this project cross municipal boundaries (check one)?     yes  
       no  
 
 
 
if yes, list the other town(s) in which the action is occurring (type name(s)):         ,                  
 
6. 
LOCATION (click on hyperlinks for information):  USGS quad map name:    Niantic    or   quad number:    101 
 
 
 
subregional drainage basin number:    2000           
 
7. 
NAME OF APPLICANT, VIOLATOR OR PETITIONER (type name):   Waterford Woods, LLC 
 
8. 
NAME & ADDRESS / LOCATION OF PROJECT SITE (type information):   384&394 Willetts Ave. Ext., 61&61A Myrock Ave. 
 
 
briefly describe the action/project/activity (check and type information):   temporary  
    permanent  
    description:   Multi-family 
 
development consisting of 3-buildings and incidental site work, installation of gravity sewer main 
 
9. 
ACTIVITY PURPOSE CODE (see instructions for codes):   C 
 
10. ACTIVITY TYPE CODE(S) (see instructions for codes):   14,    12,    10,    9 
 
11. WETLAND / WATERCOURSE AREA ALTERED (type acres or linear feet as indicated): 
  
 
wetlands:   0.10   acres             open water body:   0.00   acres           stream:   0.00   linear feet 
 
12. UPLAND AREA ALTERED (type acres as indicated):    2.23   acres 
 
13. AREA OF WETLANDS / WATERCOURSES RESTORED, ENHANCED OR CREATED (type acres as indicated):    0.10  acres 
  
DATE RECEIVED:                          PART III:  To Be Completed By The DEEP 
              DATE RETURNED TO DEEP: 
 
 
FORM COMPLETED:   YES    NO  
 
 
 
                        FORM CORRECTED / COMPLETED:   YES   NO 
 
 
GIS CODE #:  ____   ____   ____   ____   ____   ____   ____   ____   ____ 
For DEEP Use Only