Complete Form 62-620.910(12) 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: 
62-620.910(12)
Effective-Revision Date: 
Monday, October 23, 2000
Last Modified: Tuesday, Jun 18, 2024 - 06:50pm