I declare that the attached information is correct, that it is my intention to remove soil from the “
property in accordance with the attached plans and specifications and information, that I am

aware of the provisions of the City of Port Coquitlam Soil Removal Regulation Bylaw, 1993,

No. 2827 and that I will abide by all applicable provisions of the bylaw and such terms and
conditions as form part of any Soil Removal Permit issued pursuant to this Application.

Date

Signature of Applicant:

Applicant’s Name Printed:

Received from:

(Applicant's name)

this day of ,19 the sum of §$

for Soil

Deposit Permit Application Fee.

Receipt No.

City Engineer