Government of Ontario: Ministry of the Environment

Application for a Permit to Perform a Water Extermination

Personal information requested on this form is collected under the authority of the Pesticides Act, R.S.O., 1990, Ontario Regulation 63/09. It is used to evaluate applications for permits to use restricted pesticides according to the requirements of the Pesticides Act.

Questions regarding completion and submission of this application should be directed to the Pesticides Specialist in the local Regional Office of the Ministry of the Environment. Regional Office contact information is available on the Ministry of the Environment website at.

Information contained in this application form is not considered confidential and will be made available to the public upon request. Information submitted as supporting information maybe claimed as confidential but will be subject to the Freedom of Information and Protection of Privacy Act (FOIPPA) and the Environmental Bill of Rights (EBR). If you do not claim confidentiality at the time of submitting the information, the Ministry of the Environment may make the information available to the public without further notice to you. If you are identifying confidential material, please indicate why you believe the information is confidential.

Applicant Information

Home Telephone Number
Business Telephone Number  
Mailing Address

Pesticide and Site Information

Type of application


Has a permit been previously issued for this proposed treatment site?


Is the treatment to be done by an exterminator?


Area to be treated (attach a map and indicate access route)

If for Black fly treatment

Address of treatment site(s) (if different than address of applicant)

Water in the vicinity of the treated area is to be used for

Have all adjacent landowners, lessees or affected parties been notified of the
proposed treatment, realizing use of the water may be temporarily restricted?


Are there any objections to the proposed treatment from adjacent landowners, lessees or affected parties?


Have all objectors been made aware that any comments and submissions on
the proposed treatments can be made to the Director under the Act at your
nearest Ministry of the Environment Regional Office within 5 days of being
notified of the proposed treatment?


Telephone Number