Form Dsss 41 - Application For Swim Line Permit - Department Of Safety - New Hampshire
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4STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
DIVISION OF SAFETY SERVICES
MARINE PATROL BUREAU
31 DOCK ROAD
GILFORD, NH 03249-7627
APPLICATION FOR SWIM LINE PERMIT
(PLEASE TYPE OR PRINT)
NOTE: Swim Line Permits are required on ALL public bodies of water.
DIRECTIONS: Complete this form and return it to the address indicated above. INCOMPLETE
APPLICATIONS WILL BE RETURNED.
1. Check One: This is a
NEW application
RENEWAL application
2. Type of swim area for which permit is requested:
a.
Private / Individual
c.
Public:
1.
Town Owned
b.
Private Group / Association
2.
State Owned
Name of Association:
3. a. Property Owner:
DOB:
Day Phone:
Mailing Address:
Evening Phone:
Town:
State:
Zip:
DOB:
Day phone:
b. Person completing application:
Mailing Address:
Evening Phone:
Town:
State:
Zip:
4. Swim Line Location:
a. Body of Water:
b. Shorefront Property Street Address:
City / Town:
State:
Zip:
c. Lot Number and Tax Map Number:
d. Name / address of abutters to your shore front property:
1.
2.
DSSS 41 (Rev.05/01)
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