APPLICATION FOR SURFACE WATER ASSESSMENT ADJUSTMENT

APPLICATION FOR SURFACE WATER ASSESSMENT ADJUSTMENT

FOR QUESTIONS OR APPPOINTMENTS, PLEASE CALL (727) 464-8759

SECTION A - APPLICANT INFORMATION

Property Owner Name: *

Street Address *

City *

State *

Zip Code *

Phone Number *

FAX Number

Email Address *

SECTION B - PROPERTY INFORMATION

Name of Property (e.g. Development or Subdivision): *

Parcel Identification Number (PIN): *

Site Address

Site City

Site State

Site Zip Code

SECTION C – DETAILS OF REQUEST FOR ADJUSTMENT

Type of Property *

Single Family

Multi Family

Non Residential

Currently Billed Impervious Area (Sq. Feet): *

Proposed Impervious Area (Sq. Feet): *

Detailed Description of Reason for Adjustment Application:

Please attach any property maps or measurements that may be needed to determine your adjustment. A detailed topographic survey or other site specific information may be required.

*

Attachment

SECTION D – APPLICATION CHECKLIST

Complete application requesting an Adjustment
Evidence supporting the basis for the adjustments (photos, plans, etc) including the opinion of a certified professional engineer or surveyor where applicable

Incomplete applications will be denied and must be resubmitted. Please note that the County reserves the right to request additional information if necessary.

SECTION E – CERTIFICATION STATEMENTS

CLICK BELOW CERTIFYING THAT YOU HAVE READ THE FOLLOWING STATEMENTS AND UNDERSTAND EACH ONE: (By clicking and submitting you have electronically signed this application) *

I hereby certify that the information in this application is truthful and accurate.

I hereby grant the Pinellas County access to the property referenced in this document to confirm any of the information stated in this application to determine my adjustment. *

Agree

Owner or representative's name: (For multiple owners, representative responsible for management may sign.) *

Date *

OPTIONAL

If you have submitted this certification as a Florida Registered Professional, you may wish to sign and seal this certification, and return a copy to the Department, in accordance with your professional practice act requirements under Florida Statutes.

I,

License No.

Do hereby certify that the above information is true and accurate, based upon my knowledge, information and belief.

Agree

E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity. Instead, contact this office by telephone (727) 464-8759
or in writing, via the United States Postal Service to:

Pinellas County Surface Water Assessment
22211 US 19 N – Building 10
Clearwater, FL 33765