Form Dsss 19 - Application For A Congregate Mooring Field Permit
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4Application Number:________________________
DECAL #
________________________________________
Permit Number:____________________________
________________________________________
________________________________________
________________________________________
Conditions:_______________________________
________________________________________
_________________________________________
_________________________________________
# OF MOORINGS APPROVED _____________
FOR OFFICIAL USE ONLY_________________________________________________________________________________
APPLICATION FOR A CONGREGATE MOORING FIELD PERMIT
Instructions:
This application should be used for all non-public mooring fields consisting of five or more moorings. The
application must be completed in its entirety with all the required documentation. Mail the completed application to:
Department of Safety – Division of State Police
Moorings Program
P. O. Box 1150, Belmont, NH 03220
Telephone: 603-267-6453
Applicant’s name: _____________________________________________________________________
Shorefront property location:
________________________________________________________________________
___________________________________________________________________________________
Town/City: ___________________________________Phone #: ________________________________
NOTE: The applicant must be the owner or leaseholder, such as the Association, Corporation, Camp, etc., of the shore
front property accessing the mooring field.
Contact Person: ______________________________________________________________________
Mailing Address: __________________________City: _______________State:_______Zip:_________
Phone #: _________________Local Phone #: _________________ Cell Phone #:___________________
The proposed mooring field is located on Lake:_______________
The town/city tax lot number of the shore front property is:_____________________________________
Number of moorings requested: ____________ Applicant’s shore frontage in feet:___________________
The approximate area (size) of the mooring field in square feet:_________________________________
The distance from shore to the furthest proposed mooring in feet is:___________________
The number of docks at the property:______The number of boat slips:______Is there a swim line?______
Is there a swim raft at the property? ______ What is the square footage of the raft? _________________
Does the applicant have title ownership to the shore front property?________________
DSSS 19 (Rev. 08/12)
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