Wr-82 - Permit Application Form
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210 V.S.A. Chapter 47
Permit Application Form WR-82
For DEC Use:
:________________
Application #
PIN: ___________________Reviewer: ________Receive date:___________________Title 3:
Y
N
Check #:_________________ Amount: $______________ Paid By: ________________________________________
Application For: (Check one)
Attach Schedule:
Action Requested: (Check one)
Municipal Discharge Permit
A
Original Permit
Industrial Discharge Permit
B
Renewal
Pretreatment Discharge Permit
B
Amendment
Emergency Pollution Permit
E
Transfer
Permit # _______________
Status of Discharge: (Check one)
Nature of Waste: (Check one)
Proposed
Sanitary (domestic sewage only)
Existing
Non-Sewage/Industrial
A. Applicant Contact Information
1. Name:
2. Legal Entity:
(Individual, corporation, partnership, firm, state agency, municipality, etc.)
2a. Mailing Address:
2b. Municipality:
2c. State :
2d. Zip:
3. Phone:
4. Email Address:
5. Fax:
B. Project Activity:
1. Name of Activity:
2. Description of waste:
3. Type of Activity:
(Residential subdivision, paper mill, state park, motel, etc.)
4. Name of Landowner:
5. Location:
6. Town:
C. Permit Renewal:
1. If this application is for a permit renewal, is the previous application still valid in all respects?
Yes
No
If no, document changes on a separate attachment.
(Note: appropriate Schedule must be completed regardless if changes have occurred.)
WR-82 Revised 2/2016
Page 1 of 2
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Parent category: Business