WATER SERVICES INDUSTRY ACT 2006 FORM WSIA/PDC/ WATER SERVICES INDUSTRY (PLANNING, DESIGN AND CONSTRUCTION OF SEWERAGE SYSTEM AND APPLICATION FOR SEWERAGE PLANNING APPROVAL To: Sewerage Certifying Agency We SEPTIC TANK) RULES 2013, hereby apply for the approval of the sewerage planning to undertake the following sewerage works/sepiic tank works": Details of tand 4, Address/Lot No. of land occupied by sewerage works/septic tank works" 2. Area of land occupied by sewerage works (@) Sewage Treatment Plant (©) Pumping Station (Note: * delete where appropriate) acres Ee PE) TYPE E TOTAL PE REMARKS, Residential Commercial Institutional - Industial Others - a Total Development PEFORM WSIA/PDC/ Declaration by Owner ' the owner of the land where the sewerage works/septic tank works* will be carriod hereby agree for said works to be carried out on the land. ‘Signature of Owner Name of Owner (in biock letters) 1G.No, Address, Telephone No. Fax No, E-mail Declaration by Developer hereby declare thet the Information given are complete, true and accurate and this projectidevelopment shall be carried ‘out in strict compliance with the Water Services Industry Act 2006 and ils subsidiary legislations. | accept full responsibility to onsure all relovant works shall be completed accordingly. ‘Signature of Developer Name of Developer (in block letters) 1No. Address ‘Telephone No. Fax No. Emel (ote: * delete whore appropriate)FORM WSIA/PDC/T Declaration by Competent Person T hereby certify that details in this form and all documents attached are complete and accurate. | furlher certify that the sewerage planning has been prepared in pursuant to the Water Services industy (Planning, Design And Construction Of ‘Sewerage System And Septic Tank) Rules 2013. ‘Signalure of Competent Person Name of Competent Person {in block ietters) : LeNo Address ‘Telephone No. Fax No. E-mail address Foo details: ‘Type of payment : “Bank Draft (Government Cheque Issuing Bank Date Amount ‘Cheque no. Validity (Note: * dolete where appropiate) FOR OFFICIAL USE ONLY Receipt No Reference No,