Form Bwse Pa02 – Fill Out and Use This PDF

BWSE-PA02 (10/11)

State of New Jersey

DEPARTMENT OF ENVIRONMENTAL PROTECTION

Mail Code 401-03 Division of Water Supply & Geoscience –

Bureau of Water System Engineering

401 East State Street - P. O. Box 420, Trenton, New Jersey 08625-0420

Standard Application Form to Extend a Permit Term of

Permits to Construct/Modify/Operate Public Water Works Facilities

Or State Certification of 50 or More Realty Improvements

1.*Applicant/Owner:

Permanent Legal Address:

City/Town

State

Zip Code

Telephone (

)

Fax Number (

)

Name of Public Water System

PWSID #

Public Water System e-mail address

2.

Permit Number WCP

Issuance Date:

Current Expiry Date:

Project Description:

3.In accordance with N.J.A.C 7:10-11.5(m) I hereby request an extension of time of two years for the above referenced permit that has not been completed.

4.Reason for the Extension of Time Request:

5.*APPLICANT’S CERTIFICATION

I certify under penalty of law that the information provided in this document is true, accurate and complete. I am aware that there are significant civil and criminal penalties for submitting false, inaccurate or incomplete information.

In accordance with N.J.A.C. 7:10-11.5(m) I hereby certify that:

a. there has been no significant change in any of the following between the date the existing permit was issued and the date the application for extension is submitted:

i. The project and activities that were approved in the existing permit including projected demand if applicable; and

ii.There is available firm capacity and water allocation determined in accordance with N.J.A.C. 7:10-11.5(e).

b.The permit holder is not in receipt of a Department order regarding a violation of any of the terms of the existing permit.

c.The permit has not expired.

d.This request to extend a permit has been submitted to the Department at least 90 days prior to expiration date of the existing permit.

		_________________________________________
Type: Name			* Signature of Applicant/Owner’s Authorized Representative
Type: Position			Date of Application

Please note that all signatures shall be originals and not photocopies.

*Please note that for all requests other than Certification of 50 or More Realty Improvements the applicant shall be the Public Water System and not a developer, land owner or engineering firm, etc.

This form is available at www.state.nj.us/dep/watersupply