Complete Form 62-621.500(2)(c) by clicking on the document (pdf) below.

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’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: 
62-621.500(2)(c)
Effective-Revision Date: 
Tuesday, February 7, 2006
Last Modified: Tuesday, Nov 19, 2024 - 10:45am