I,...(full name) being the applicant residing at the below address, apply to the Waitaki District Council for Landuse Resource Consent. Address:.

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1 APPLICATION FOR LANDUSE RESOURCE CONSENT (Section 88 of the Resource Management Act 1991) Form 9 Use this form to apply to Waitaki District Council for Landuse Resource Consent in the instance that a proposal is unable to comply with the provisions of the District Plan. We recommend, in order to avoid unnecessary delay in processing, that planning staff be consulted upon lodging application to determine the receipt of all required information, including written consent of affected persons. Please be aware that these details are available to the public. I,...(full name) being the applicant residing at the below address, apply to the Waitaki District Council for Landuse Resource Consent. Address:. Phone: (work) (home) Cell address.. The site details of the location at which the below described activity is to take place are: Street address: Rapid Number: Legal description:... Valuation number (if known): The names and address of the owner/occupier (other than the applicant) of any land to which this application relates are as follows: Name: Mailing address:... Contact phone:. NOTE: The owners WRITTEN PERMISSION of the application must accompany this application. FULL DESCRIPTION OF THE ACTIVITY & JUSTIFICATION OF NON-COMPLIANCE (statement specifically explaining degree of non-compliance, including all details that clearly identify the proposal enabling planning staff to fully determine the extent of the activity and its impacts. Scaled plan to be included where appropriate.) We recommend you consult with a Planner prior to lodging the application..

2 (any further information should be attached to your application) I include an assessment of any effects that the proposed activity may have on the environment in accordance with Section 88 of, and the Fourth Schedule to, the Resource Management Act You will probably need to complete this on a separate piece of paper and attach it to this application form. I include other information (if any) required to be included in the application by the District or Regional Plan or Regulations (for example: written consents, location plan, scaled plan, traffic assessment, building plans, noise assessment). Hazardous Activities and Industries List (HAIL) Is the site on which the land use activity relate to a HAIL site (refer to attached information sheet)? Yes No Please note that as well as industrial type activities this list also includes, but not limited to, agricultural and horticultural activities. If the answer is Yes you must provide an assessment of the proposal against the National Environmental Standard for Assessing and Managing Contaminants in Soils. A deposit fee must accompany your application. If the costs incurred in processing this application exceed the deposit, the applicant will be invoiced for the balance. I enclose the required DEPOSIT FEE of: $ deposit for a Non-notified application $ deposit for size / location Infringement with written approvals. $3, deposit for a Limited Notified application (likely to exceed $ deposit) $6, deposit for a Notified application (likely to exceed $ deposit) NOTE: PLEASE RESEARCH THE FULL EXPECTED COST OF YOUR APPLICATION PRIOR TO LODGEMENT. FAILURE TO APPRECIATE THE POTENTIAL COST LIABILITY BY AN APPLICANT PRIOR TO LODGMENT OF AN APPLICATION WILL NOT BE A BASIS FOR LATER ARGUMENTS ABOUT COSTS.

3 1 st point of contact for correspondence: address. Billing address:..... Signature of applicant(s) or person authorised to sign on their behalf Sign Date (you may apply for 2 or more resource consents that are needed for the same activity on the same form) COUNCIL PLANNING OFFICER TO COMPLETE: Pre-application meeting..y / N (Circle one) A phone call or front counter discussion is not considered a pre-application meeting. Dates & Time taken for pre-application meeting This is important information for MfE Report Accepting Planner Initials. Date..Time Paid Internal Depts (circle as appropriate): Roading Water & Sewerage Drainage Building Health

4 Does your application contain... a detailed description of the existing site? a statement as to why the activity is necessary at that site? a description of any filling or excavation earthworks (the type, volume and depth of fill; where on the site these are located)? the results of any consultation undertaken with any parties who may be affected? In the description have you considered... the materials and colours to be used on the exterior cladding of any proposed building? any geological or other natural hazards? will the activity require car parking and access to be provided? will any landscaping work such as the planting of trees be done? any signs or advertising involved? will the activity generate noise? any odours generated? will increased glare result or is extra lighting involved? any other emissions generated such as dust, fumes and/or radio emissions? any hazardous substances to be stored or used on the site? any protected trees or nature conservation areas on-site or nearby? any listed heritage items? any impact on recreational uses? any other resource consents required? Drawings and Plans Drawings should show the location of the site with road name, property number, north point and any significant built or topographical features. A site plan of the property, at a scale of not less than 1:200, should show: side boundary lengths and other dimensions in metres distances to side boundaries of all existing and proposed buildings and structures on the site the proposed use of each building position of any easement over the site location of roads adjacent to the site and the formation status of the road and any footpaths location of all vehicle access points and driveways at the street boundary position, location and dimensions of every parking and loading space kerb lines adjacent to the site and the position of any street trees levels on the site boundaries; around any buildings the contours of the site (except where the site area is less than 1000m 2 or has a uniform grade of less than 1:10) any proposed retaining walls, excavations and landfill existing trees and proposed landscaping and the dimensioned areas of the landscaping. Also, all existing and proposed sealed areas indigenous vegetation areas, streams, wetlands and heritage items where relevant, recession line diagrams or models watercourses and drainage and sewerage pipes within and adjacent to the site the means proposed to deal with all stormwater and sanitary drainage and to provide for water supply

5 location of any water supply bores and effluent disposal areas on the site and on adjoining sites A floor plan of each proposed building (at a scale of not less than 1:100) should show: use of all parts of the building room layout of the building, if known, and the use of the different rooms A diagram of the elevations of each proposed building (at a scale of not less than 1:100) should show: the external appearance of the building including doors and windows number of floors and their proposed usage building heights and height in relation to each boundary A subdivision consent application must include: the position of all new and existing boundaries areas of all new allotments to be created location and areas of any new reserves to be created including esplanade reserves location and areas of any esplanade strips to be created the location and areas of any existing esplanade reserves, esplanade strips or access strips the location and areas of any land below Mean High Water Springs of the sea or of any part of the bed of a river or lake, which is required to be vested in the Crown the location and areas of land to be set aside as new road Matters that should be included in an assessment of effects on the environment: Description of proposal Description of possible alternative locations or methods for undertaking the activity Assessment of actual or potential effect on the environment of the proposed activity Where the activity includes the use of hazardous substances and installations, an assessment of any risks to the environment which are likely to arise from such a use Description of mitigation measures (safeguards and contingency plans where relevant) to be undertaken to help prevent or reduce the actual or potential effect Identification of those persons interested in or affected by the proposal, the consultation undertaken, and any response to the views of those consulted Where the scale or significance of the activity s effect are such that monitoring is required, a description of how, once the proposal is approved, effects will be monitored and by whom

6 Hazardous Activities and Industries List (HAIL) October 2011 A. Chemical manufacture, application and bulk storage 1. Agrichemicals including commercial premises used by spray contractors for filling, storing or washing out tanks for agrichemical application 2. Chemical manufacture, formulation or bulk storage 3. Commercial analytical laboratory sites 4. Corrosives including formulation or bulk storage 5. Dry-cleaning plants including dry-cleaning premises or the bulk storage of dry-cleaning solvents 6. Fertiliser manufacture or bulk storage 7. Gasworks including the manufacture of gas from coal or oil feedstocks 8. Livestock dip or spray race operations 9. Paint manufacture or formulation (excluding retail paint stores) 10. Persistent pesticide bulk storage or use including sport turfs, market gardens, orchards, glass houses or spray sheds 11. Pest control including the premises of commercial pest control operators or any authorities that carry out pest control where bulk storage or preparation of pesticide occurs, including preparation of poisoned baits or filling or washing of tanks for pesticide application 12. Pesticide manufacture (including animal poisons, insecticides, fungicides or herbicides) including the commercial manufacturing, blending, mixing or formulating of pesticides 13. Petroleum or petrochemical industries including a petroleum depot, terminal, blending plant or refinery, or facilities for recovery, reprocessing or recycling petroleum-based materials, or bulk storage of petroleum or petrochemicals above or below ground 14. Pharmaceutical manufacture including the commercial manufacture, blending, mixing or formulation of pharmaceuticals, including animal remedies or the manufacturing of illicit drugs with the potential for environmental discharges 15. Printing including commercial printing using metal type, inks, dyes, or solvents (excluding photocopy shops) 16. Skin or wool processing including a tannery or fellmongery, or any other commercial facility for hide curing, drying, scouring or finishing or storing wool or leather products 17. Storage tanks or drums for fuel, chemicals or liquid waste 18. Wood treatment or preservation including the commercial use of anti-sapstain chemicals during milling, or bulk storage of treated timber outside B. Electrical and electronic works, power generation and transmission 1. Batteries including the commercial assembling, disassembling, manufacturing or recycling of batteries (but excluding retail battery stores) 2. Electrical transformers including the manufacturing, repairing or disposing of electrical transformers or other heavy electrical equipment 3. Electronics including the commercial manufacturing, reconditioning or recycling of computers, televisions and other electronic devices 4. Power stations, substations or switchyards C. Explosives and ordinances production, storage and use 1. Explosive or ordinance production, maintenance, dismantling, disposal, bulk storage or re-packaging 2. Gun clubs or rifle ranges, including clay targets clubs that use lead munitions outdoors 3. Training areas set aside exclusively or primarily for the detonation of explosive ammunition

7 D. Metal extraction, refining and reprocessing, storage and use 1. Abrasive blasting including abrasive blast cleaning (excluding cleaning carried out in fully enclosed booths) or the disposal of abrasive blasting material 2. Foundry operations including the commercial production of metal products by injecting or pouring molten metal into moulds 3. Metal treatment or coating including polishing, anodising, galvanising, pickling, electroplating, or heat treatment or finishing using cyanide compounds 4. Metalliferous ore processing including the chemical or physical extraction of metals, including smelting, refining, fusing or refining metals 5. Engineering workshops with metal fabrication E. Mineral extraction, refining and reprocessing, storage and use 1. Asbestos products manufacture or disposal including sites with buildings containing asbestos products known to be in a deteriorated condition 2. Asphalt or bitumen manufacture or bulk storage (excluding single-use sites used by a mobile asphalt plant) 3. Cement or lime manufacture using a kiln including the storage of wastes from the manufacturing process 4. Commercial concrete manufacture or commercial cement storage 5. Coal or coke yards 6. Hydrocarbon exploration or production including well sites or flare pits 7. Mining industries (excluding gravel extraction) including exposure of faces or release of groundwater containing hazardous contaminants, or the storage of hazardous wastes including waste dumps or dam tailings F. Vehicle refuelling, service and repair 1. Airports including fuel storage, workshops, washdown areas, or fire practice areas 2. Brake lining manufacturers, repairers or recyclers 3. Engine reconditioning workshops 4. Motor vehicle workshops 5. Port activities including dry docks or marine vessel maintenance facilities 6. Railway yards including goods-handling yards, workshops, refuelling facilities or maintenance areas 7. Service stations including retail or commercial refuelling facilities 8. Transport depots or yards including areas used for refuelling or the bulk storage of hazardous substances G. Cemeteries and waste recycling, treatment and disposal 1. Cemeteries 2. Drum or tank reconditioning or recycling 3. Landfill sites 4. Scrap yards including automotive dismantling, wrecking or scrap metal yards 5. Waste disposal to land (excluding where biosolids have been used as soil conditioners) 6. Waste recycling or waste or wastewater treatment H. Any land that has been subject to the migration of hazardous substances from adjacent land in sufficient quantity that it could be a risk to human health or the environment I. Any other land that has been subject to the intentional or accidental release of a hazardous substance in sufficient quantity that it could be a risk to human health or the environment