Wr-82 - Permit Application Form Page 2
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2D. Discharge Schedule
2. Using a separate serial number (S/N), identify each independent discharge which will result from the
activity described above. Attach a separate schedule for each discharge identified below.
Use an attached sheet for additional discharges.
Discharge
Receiving Water
Latitude/Longitude (optional)
S/N 001
S/N 002
S/N 003
S/N 004
S/N 005
E. Application Fees
3 V.S.A. Section 2822 Fees: email jill.draper@vermont.gov for assistance calculating the application review fee.
$240.00 Administrative Processing Fee
Does not apply to Emergency Pollution Permits
Plus Application Review Fee
Applies to all applications (except for name change)
Total Fee Enclosed
F. Signature
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE INFORMATION SUBMITTED ABOVE IS TRUE, ACCURATE AND
COMPLETE. I RECOGNIZE THAT BY SIGNING THIS APPLICATION I AM GIVING CONSENT TO EMPLOYEES OF THE STATE TO ENTER THE
SUBJECT PROPERTY FOR THE PURPOSE OF PROCESSING THIS APPLICATION.
_________________________________________________________________________________________________________
NAME AND TITLE OF APPLICANT OR LEGALLY AUTHORIZED REPRESENTATIVE (please print)
_________________________________________________________________________________________________________
SIGNATURE DATE
_________________________________________________________________________________________________________
NAME AND TITLE OF CO-APPLICANT OR LEGALLY AUTHORIZED REPRESENTATIVE (please print)
_________________________________________________________________________________________________________
SIGNATURE DATE
This application must be signed by the applicant or an officer in the applicant’s business, a municipal official, etc. The application CANNOT be
signed by the applicant’s attorney, engineer, contractor, etc.
Submittal of Application: Attach appropriate schedules, administrative processing and application
review fees, plans, specifications and other supporting material.
Send completed application and fee made payable to:
VT Department of Environmental Conservation
Watershed Management Division
One National Life Drive, Main Bldg, 2
Floor
nd
Montpelier VT 05620-3522
WR-82 Revised 2/2016
Page 2 of 2
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