WATER/SEWER SERVICE AREAWSCCR
CATEGORY CHANGE REQUESTApplicant
APPLICATION DEP STAFF USE ONLYPAGE1 of 2
COMPREHENSIVE WATER SUPPLY SEWERAGE SYSTEMS PLAN AMENDMENT
Montgomery County Department of Environmental Protection
Please refer to the accompanying information and instruction packet for help with completing this application.
PROPERTY INFORMATION
PROPERTY Address
Property Identification
▲ Lot, Block, Subdivision – or – Parcel No. – Refer to Your County Property Tax Bill
Property Tax Account No.
▲ Refer to Your County Property Tax Bill
Current UseProperty/Site Size
▲ Acres or Square Feet
Proposed Use
Subdivision Plan No. & Status
Property/Site Map:A page-size (8.5"x 11") map, clearly and accurately showing the property/site boundariesneeds to accompany this application. Refer to the instructions packet for more details and resources.
CATEGORY CHANGE REQUESTCheck the boxes belowonly as appropriate.
Water CategoryCurrent:W-Requested: W-No ChangeMultiuse A
Sewer CategoryCurrent: S-_____Requested: S-No ChangeMultiuse A
Questions about current or requestedcategories?Contact DEP-WWPG staff for assistance (see pg. 2).
Applicant’s Reasonfor this Request(Attach additional pages, cover letters, etc., if necessary):
DEP STAFF USE ONLY
Received:Fee:Paid Receipt Confirmed:
Agency Review Group:Process: Admin. Del.County Council
AFor onsite systems only. Refer to the application instructions packet for information about the term “multiuse”.
Please refer to the accompanying information and instruction packet for help with completing this application.
APPLICANT INFORMATION
Only the property owner may act as the applicant for this request. DEP verifies ownership against property tax account records. Attach additional copies of this page if the request involves more than one property owner.
Property Owner’s Name
Owner’s MAILINGAddress
Email AddressB
Phone No. FAX No.
APPLICANT'S AUTHORIZATION
I am the: Property Owner Property Owner's Authorized RepresentativeC
Applicant’s SignatureDate
TitleC
ADDITIONAL CONTACT INFORMATIONC
The contact listed below is:
An engineer, attorney, contract purchaser, etc. that should also be notified of the status of this request.
To serve as DEP’s primary contact for this application.
A non-profit organization that will use but does not currently own the subject property(ies).(A non-profit organization applying for a service area change under the “PIF” policy (see instructions) for a property owned by another party serves as a co-applicant to the owner and must complete this section.)
Contact’s Name
Contact’s Address
E-mail AddressB
Phone No.FAX No.
APPLICATION FEE
Most category change requests require an application fee. Refer to the information and instructions packet for directions on calculating and paying your application fee.
DEP Water & Wastewater Policy Staff Contact Information
Alan Soukup, Sr. PlannerPhone: 240-777-7716email: EP FAX:
George Dizelos, Planner IIPhone: 240-777-7755email: 240-777-7715
BPlease provide alegible, printedemail address for all parties, as this is our standard means of communication with you. If you don’t have email access, provide a complete mailing address and weekday phone number.
CPlease refer to the application instructions packet for additional information. A contract purchaser may not act as a category change applicant, but can be listed as an additional contact (see above).
R:\Programs\Water_and_Sewer\CCRs\FORMS\FY2017-application-forms\WSCCR_App_Form_FY2017.doc
Montgomery County Department of Environmental Protection ▪ Water and Wastewater Policy Group
Rockville Center, Suite 120 ▪ 255 Rockville Pike ▪ Rockville, Maryland 20850-4166
Internet: