Non-Residential Stormwater Fee Credit Application

GENERAL INFORMATION

1.	Customer Contact Information:	
	Name/Title:	 		
	Company:	 		
	Address:	 		

Phone:	 	 Email:	 		
Account #(s)    		
Property Address:	 		
Authorized Representative (if different from above) Contact Information	
Name/Title:	 		
Address:	 		

2.
3.
4.

Phone:	 	 Email:	 		
St. Johns River Water Management District (SJRWMD) Information:	
Environmental Resource Permit (ERP) Number:    		
Permit Issuance Date:	 		
Application Submittal Checklist:	
 	  Site Map Showing Area Treated by Permitted Stormwater Facility	
 	  Copy of Effective SJRWMD Permit (if applicable)	
 	  Copy of Last SJRWMD Inspection Report (if applicable)	
 	  Copy of Report by Professional Engineer Certifying Compliance with	
SJRWMD ERP Requirements (if applicable)	
Right of Entry Declaration:	
As a condition of an approved credit, I hereby grant the District right of entry to	
the subject property for inspection of the credited facility to ensure on-going	
maintenance and performance of the facility.	(initial)	

5.

6.

7.

Signature of Property Owner	Date

Submit to:	Mail:	
	District Utility Office	
	101 Jungle Hut Road	
	Palm Coast, FL 32137	

Email:	
malvarado@dunescdd.org	

DISTRICT USE ONLY

Facility Permit is Valid?	Y	N

Valid Proof of Maintenance Provided?	Y	N

Percent of Impervious Area Treated by Stormwater Facility:  	

Credit Granted (25%):    Y     N

Current Monthly Stormwater Fee:	$	 New Monthly Stormwater Fee:	$	 Effective Date of New Monthly Fee:	 	 APPROVAL SIGNATURE: