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WATER QUALITY PROTECTION CHARGE SINGLE FAMILY RESIDENTIAL CREDIT APPLICATION
Regulated by the Code of Montgomery County Regulations (COMCOR) 19.35.01.05
Montgomery County Department of Environmental Protection

APPLICANT MUST ATTACH A COPY OF PROPERTY TAX BILL AND ALL SUPPORTING DOCUMENTATION INCLUDING PHOTOS OF THE PRACTICES FOR THE CREDIT NOT LATER THAN OCTOBER 31 OF THE YEAR BEFORE PAYMENT OF THE CHARGE IS DUE.
Property Information
Property Account No:* Owner Name:*
Premise Address:* Phone Number:
Owner/Agent Address: Phone Number (Premise):*
Email Address: I am the:*
(If Authorized Agent, please attach copy of document creating authorization at bottom of application)
Impervious Area
Building (house) square feet Year Primary Structure Built
Driveway/Parking square feet Environmental Site Design (ESD) Requirements
Other square feet ESDV Required
Total square feet Project Design  
Parcel Area : square feet Volume Captured
WQPC
Charge on Bill (before credit) WQPC Credit
Percent Credit Charge (after credit)
Stormwater Management System Information
Facility Type Facility Size Facility Size Units Quantity Quantity Units
Bio swales linear feet    
Roof Leader Disconnection to Pervious Area square feet of pervious area No. of Roof Leaders Disconnected (4 MAXIMUM)
Non-Roof Areas Disconnected to Pervious Area square feet of pervious area No. of Non-Roof Areas Disconnected (2 MAXIMUM)
Dry well     No. of Dry Wells
Green Roofs square feet  
Conservation Landscaping square feet    
Micro – Bioretention square feet  
Rain Garden with 1 foot of Planting Soil square feet    
Rain Garden with 2 feet of Planting Soil square feet    
Rain Garden with 3 feet of Planting Soil square feet    
Micro – Infiltration square feet    
Pervious Pavement square feet    
Rain Barrel - 55-Gallon gallons No. of Barrels @ 55-Gallon
Rain Barrel - 75-Gallon gallons No. of Barrels @ 75-Gallon
Rain Barrel - 100-Gallon gallons No. of Barrels @ 100-Gallon
Rain Barrel - Other (Specify Size) gallons - Other  No. of Barrels @ Other (Specify Size)
Cistern gallons No. of Cisterns
Sheet Flow to Conservation Area square feet of conservation area    
Maintenance Checklist
Maintenance Activities Dry Well Rain Garden
Bioswale
Micro-bioretention
Green Roof Rain Barrel
Cistern
Grass Swale Pervious Pavement
Inspect channels, inlets, and outlets, and remove any debris or blockages Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year
Remove weeds and invasive plants Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year
Regularly inspect for signs of erosion, bare spots, or replace unhealthy/dead vegetation Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year
After a rain storm, check to make sure that there is not standing water after 2 days Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year
Replenish and redistribute mulch to a total depth of 3 inches Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year
Regularly inspect your rain garden or micro-bioretention and have 6 inches of ponding depth Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year
Are caps on observation wells present and fastened? Date that Maintenance was Last Performed
Frequency Maintenance is Performed Per Year          
Are gutters/downspouts in good working order? Date that Maintenance was Last Performed        
Frequency Maintenance is Performed Per Year        
Is your gutter connected to your dry well? Date that Maintenance was Last Performed          
frequency Maintenance is Performed Per Year          
Permeable interlocking pavers - replace/ replenish the top layer of stone between joints with new clean stone after sweeping or vacuuming Date that Maintenance was Last Performed          
requency Maintenance is Performed Per Year          

Upload Supporting Documents and Images:*

By signing this form, you certify that (1) you have read and understand the WQPC Credit Program Requirements; (2) the information provided on this form is complete and factual; (3) the stormwater management system(s) on your property have been maintained and are in proper working order; and (4) you grant the County permission to conduct site inspections of the stormwater facilities listed on this form.
By checking this check box, I *sign this application.
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