Contact person: (if different from above)

Phone no:

Mobile no:

Email address:

Postal address:

Post code:

Fax no:

Best contact time:

Please tick each of the following consents you are applying for and attach the respective application forms to the back of this form:

Drilling of WellLodgment fee $320 incl GST

Land Disturbance / Vegetation ClearanceLodgment fee $885.50 incl GST

Surface Water TakeStock Water: lodgment fee $977.50 incl GST

Irrigation: lodgment fee $1,207.50 incl GST

Other: lodgment fee $885.50 incl GST

Ground Water TakeStock Water: lodgment fee $908.50 incl GST

Irrigation: lodgment fee $1,863 incl GST

Other: lodgment fee $885.50 incl GST

Dairyshed DischargeLodgment fee $1,012 incl GST

Land use for intensive farming and associated dischargesLodgment fee $885.50 incl GST

Addition of Land Parcels to DairyshedEffluent Discharge AreaNo charge

Works in a WaterbodyLodgment fee $885.50 incl GST

Gravel ExtractionLodgment fee within allocation $1,667.50 incl GST

Discharge to AirLodgment fee $885.50 incl GST

Discharge to Land

Lodgment fee $885.50 incl GST

Change of Consent ConditionsLodgment fee $885.50 incl GST

Other$885.50 incl GST

Consent holder name:

Please note: Resource Consents in the name of a Trust, Estate or Partnership require a contact list of all trustees/partners to be attached to any application. Consents can also be issued to a person(s) or to a company.

MANAGING OUR ENVIRONMENT

RESOURCE CONSENTPART A: APPLICATION FORM COVER SHEETThis form needs to be completed with all consent applications submitted to Horizons Regional Council. If sending multiple applications this cover form only needs to be completed once.

11-15 Victoria AvenuePrivate Bag 11025Manawatu Mail CentrePalmerston North 4442

T 0508 800 800F 06 952 2929oneplan@horizons.govt.nzwww.horizons.govt.nz

2016/644

Ring Horizons Regional Council’s Consents Team on freephone 0508 800 800 if you require any assistance

The information provided on this form will be used to process the consent application and, if granted, to monitor the exercise of the consent. The information requested is required by the Resource Management Act 1991. Horizons Regional Council may disclose the information if a request is made by another party, under provisions of the Local Government Official Information and Meetings Act. Horizons Regional Council may also publicly disclose some of this information in circumstances where consent conditions have been breached. Under the Privacy Act 1993, you have the right of access to personal information about you held by Horizons Regional Council and you are also entitled to request information about you to be corrected.

Signature of applicant: (or person authorised to sign on behalf of the Applicant)

Address for service of applicant if different from above:

Phone no:

Mobile no:

Contact person:

Location/ property address of the proposed activity

Legal description of all land titles (this can be found on your rates demand):

Valuation numbers for all land titles (this can be found on your rates demand):

Map reference (if known):

Ring Horizons Regional Council’s Consents Team on freephone 0508 800 800 if you require a map

Do you own the property where this activity will take place?

If no, please state owner of property?

Contact details of property owner:

Yes No

Please note that written approval is required from this landowner and should accompany this application

Contact person at Horizons Regional CouncilIf you have already dealt with a member of the consents team please advise their name?

Have you attached the following:

Activity application forms as ticked above

Assessment of Environmental Effects

Map showing location and all required points of reference as requested on the activity application form

Lodgment fee

Please note: If you do not provide enough information your application may not be accepted. All furthercorrespondence will be sent electronically unless otherwise specified.

I would like to receive all correspondence as hardcopy. I would like to receive all correspondence electronically.

MANAGING OUR ENVIRONMENT

Application gravel extraction

Consent holder:

Contact person:

Is this application replacing a current consent? Yes No If yes, do you agree to surrender your current consent should this application be granted? Yes No

Current consent number if applicable:

If this application is for the renewal of an existing extraction, please provide actual annual volumes extracted

under the existing consent: ________________________________________________________________________

GPS coordinates of extraction site as indicated on plan: E 2 _________________ N 6 _________________

Waterbody name: (eg river / stream / lake name)

Quantity of gravel applied for: _______________________________ cubic metres per year (m3/year)

_______________________________ cubic metres over the entire consent duration

Will you be processing (washing or crushing) gravel at the site? Yes No

If yes, please provide further detail on water supply and discharge, how this will be managed and indicate proposed processing areas on the site plan included (Please note: further consents may be required).

Is this site used for recreational purposes? (eg fishing or walking) Yes No

If yes, please describe: ____________________________________________________________________________

Are river crossing required as part of this application? Yes No

If yes, where (please indicate on site plan included) and how frequently? _____________________________________

Will your application result in the permanent diversion of the waterbody? Yes No

If yes, please provide further detail and indicate proposed diversion on the site plan included (Please note: further consents may be required).

Continued Overleaf

2015

Please provide the following:

Photos of the extraction area, 50 metres upstream and 50 metres downstream of the extraction Site Plan, including but not limited to, extraction, storage and stock pile areas Cross sections of extraction area, and 50 metres upstream and 50 metres downstream for

extractions over 5,000 cubic metres per year

Please note there may also be a need to obtain consent from the District / City Council.

Have you had contact with the Regional Council Operations Department? If you have please indicate what the results of that consultation were on a separate page.

Please note: if you do not provide enough information your application may not be accepted

Fees and charges A lodgement fee of $1,667.50 (incl GST) is required with your application. Failure to send this fee may result in rejection of your application. Please Note: there may be circumstances where additional charges may be incurred (i.e. outside of allocation and / or notification). If you would like to pay your lodgement fee via internet banking please make payment to 02-0630-0024883-003, please

insert CONSENT HOLDER NAME in reference and CONSENTS in code.

Signature of applicant: _________________________________________________ Date: ____________________ (or person authorised to sign on behalf of the Applicant)

Ring Horizons Regional Council’s consents team on freephone 0508 800 800 if you require assistance.

The information provided on this form will be used to process the consent application and, if granted, to monitor the exercise of the consent. The

information requested is required by the Resource Management Act 1991. Horizons Regional Council may disclose the information if a request is made

by another party, under provisions of the Local Government Official Information and Meetings Act. Horizons Regional Council may also publicly

disclose some of this information in circumstances where consent conditions have been breached. Under the Privacy Act 1993, you have the right of

access to personal information about you held by Horizons Regional Council and you are also entitled to request information about you to be corrected.

2015

Describe the physical attributes of the site(s) (eg topography, ecology, bed materials, One Plan Schedule AB Values, wildlife habitats, cultural and scientific features).

Continue on a separate sheet if necessary

Describe the actual and potential effects that the proposed activity/operation could have on the environment (eg sediment discharge, flood passage, water quality, fish passage etc.)

Continue on a separate sheet if necessary

What methods or actions will be used to reduce or prevent any identified environmental effects (as identified above), include and attach any Erosion and Sediment Control and /or Flood Contingency Plans, etc

Continue on a separate sheet if necessary