Complete Form 62-640.210(2)(a) 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.

Please email the completed form to the appropriate DEP District Office or delegated local program.

 

Form Number: 
62-640.210(2)(a)
Effective-Revision Date: 
Monday, June 21, 2021
Last Modified: Thursday, Sep 17, 2026 - 11:45am