Complete Form 62-640.210(2)(d) by clicking on the document (pdf) above.

Please review the Electronic Submission Instructions and Domestic Wastewater Permit Application Fees documents prior to submitting a form electronically.

To submit this form electronically, please email the completed form to the appropriate DEP District Office’s email address

Note, if your facility is regulated by a delegated local program and you want to submit the form electronically, please contact your delegated local program.

Form Number: 
62-640.210(2)(d)
Effective-Revision Date: 
Monday, June 21, 2021
Last Modified: Friday, Dec 13, 2024 - 05:38pm