WATER/SEWER SERVICE AREA WSCCR
CATEGORY CHANGE REQUEST Applicant
APPLICATION DEP STAFF USE ONLY PAGE 1 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. – See Your County Property Tax Bill
Property Tax Account No.
▲ See County Property Tax Bill
Current Use Property/Site Size
▲ Acres or Sq. Ft.
Proposed Use
Subdivision Plan No. & Status
Property/Site Map: A page-size (8.5"x 11") map, clearly and accurately showing the property/site boundaries must accompany this application. Refer to the instructions packet for more details and resources.
CATEGORY CHANGE REQUEST Check the boxes below only as appropriate.
Water Category Current: W- Requested: W- £ No Change £ Multi-Use A £ Shared A
Sewer Category Current: S- ____ Requested: S- £ No Change £ Multi-Use A £ Shared A
Questions about current or requested categories? Contact DEP-WWPG staff for assistance (see pg. 2).
Applicant’s Reason for this Request (Attach additional pages, cover letters, etc., if necessary):
DEP STAFF USE ONLY
Received: Fee: Paid c Receipt Confirmed:
Agency Review Group: Process: Admin. Del. c County Council c
Planning Area: WSSC Tile: Tax Map:
Master Plan (Date)
Zoning: Recent Zoning Activity:
Major Watershed: MDE Watershed Use: Mont. Co. SPA c
A Refer to the application instructions for information about the terms “multi-use” and “shared”.
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 MAILING Address
E-mail Address B
Phone No. FAX No.
APPLICANT'S AUTHORIZATION
I am the: £ Property Owner □£ Property Owner's Authorized Representative C
Applicant’s Signature Date
Title C
ADDITIONAL CONTACT INFORMATION C
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 Address B
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. Planner ▪ Phone: 240-777-7716 ▪ FAX: 240-777-7715 ▪ e-mail:
B Please provide an e-mail address for all parties. E-mail is our standard means of communication and notification. If you don’t have e-mail access, provide a complete mailing address and weekday phone number.
C Please 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\Projects\FORMS\CCR_APPS\WSCCR_App_Form_FY2012.doc
Montgomery County Department of Environmental Protection ▪ Water and Wastewater Policy Group
Rockville Center, Suite 120 ▪ 255 Rockville Pike ▪ Rockville, Maryland 20850-4166
Internet: www.montgomerycountymd.gov/waterworks