Application for Land Use Permit

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Privacy Act Statement

The information you provide in this document is collected under the authority of the Territorial Land Use Regulations for the purpose of responding to your application for land use permit. Information on individuals is used by Aboriginal Affairs and Northern Development Canada Land Administration employees who need to know the information in order to respond to your request and/or the program requirements. We share the information you give us with First Nations, Aboriginal groups and Inuit, Territorial and Federal Government Expert Agencies and Public Government Institutions. The personal information will be retained 6 years after the last administrative use and then destroyed. Individuals have the right to the protection of and access to their personal information under the Privacy Act  .

For Office Use Only
Application Fee:

Land Use Fee:

General Receipt No.:
Date: (YYYY/MM/DD) 

Class:

Permit Number:
To be completed by all applicants
  • New Application
  • Amendment
1. Applicant’s Name and Mailing Address (Full name, no initials):



Facsimile No. 
__________________
Telephone No.
2. Head Office Address:



Facsimile No. 
__________________
Telephone No.
Field Supervisor:

Radio Telephone:
E-Mail Address:

Telephone Number:
3. Other Personnel (Subcontractor, Contractors, Company Staff, etc.):
 
 
 
 

Total: __________________

4. Qualifications

Refer to Section 21 of the Territorial Land Use Regulations

___a(i)   ___a(ii)   ___a(iii)   ___b   ___c

Number(s) exploration permit mineral claims (If applicable): __________________

5.
  1. Summary of Operation (Describe purpose, nature and location of all activities.)
    Refer to Section 22(2)(b) of the Territorial Land Use Regulations (Use last page of form if necessary.)
     
     
     
     
  2. Please indicate if a camp is to be set up (Use last page to provide details.)


6. Summary of potential environmental and resource impacts (Describe the effects of the proposed program on land, water, flora and fauna and related socio-economic areas.)
(Use separate pages if necessary.)
 
 
 
 
7. Proposed Restoration Plans (Please use last page if required.)
 
 
 
 
8. Other rights, licences or permits related to this permit application (Mineral claims, Yukon timber permits, water licences, etc.)
(Please use last page if required.)
 
 
 
 

Roads:

  •  
  • Is this to be a pioneered road?
  • Has the route been laid out or ground truthed?
9. Proposed Disposal Methods (Please use last page if required.)

 
a) Garbage:


b) Sewage (Sanitary and Grey Water):
 
c) Brush and Trees:


d) Overburden (Organic soils, waste material, etc.):
10. Equipment (Includes drills, pumps, etc.) (Please use last page if required.)
Type and Number
Size
Proposed Use
 

 

 
 

 

 
 

 

 
 

 

 
 

 

 
11. Fuels
Number of Containers
Capacity of Containers
___Diesel

 

 
___Gasoline

 

 
___Aviation Fuel

 

 
___Propane

 

 
___Other____________

 

 
12. Containment Fuel Spill Contingency Plans (Please attach separate contingency plan if necessary.)



 
13. Methods of Fuel Transfer (To other tanks, vehicles, etc.)



 
14. Period of Operation (Includes time to cover all phases of project work applied for, including restoration.)



 
15. Period of Permit (Up to two years, with maximum of one year extension.)


Start Date: (YYYY/MM/DD)

Completion Date: (YYYY/MM/DD)
16. Location of activities by map co-ordinates (Attach maps and sketches.)

Minimum Latitude

  • Degrees: _________
  • Minutes: _________
  • Seconds: _________

Minimum Longitude

  • Degrees: _________
  • Minutes: _________
  • Seconds: _________

Maximum Latitude

  • Degrees: _________
  • Minutes: _________
  • Seconds: _________

Maximum Longitude

  • Degrees: _________
  • Minutes: _________
  • Seconds: _________
Map Sheet Number:


17. Applicant (Print Full Name)


Signature:


Date: (YYYY/MM/DD) 
18. Fees
  • Class A - $150.00
  • Class B - $150.00
$150.00
Land Use Fees: Less than or equal to 2 hectares of $50.00

$50.00
For each additional hectare over 2 hectares or portion of a hectare
X $50.00
 
Total application and land use fees =   

 
 For Office Use Only
19. Calculation of area involved (Includes access, staging areas, airstrips, campsites, etc.)

Total Area (Ha)


Less than or equal to 2 hectares

Total (For Fee Calculation)
20. Application Checklist

____a) Application Signed and Dated

____b) Fees Attached

____c) Map Included

____d) Address and Telephone Number

____e) Screening Report

____f) Timber Permit Applied for - Yukon_

____g) Fees Attached

____h) Lease Applied for

Remarks (Please use last page if additional space is required.)



Accepted by

Date: (YYYY/MM/DD) 
21. Additional Information (Attach additional pages if necessary.)

 

 

 

 

 


 

INTER 50-019 E 2012-04-01