FORM WSIA/PDC/2 WATER SERVICES INDUSTRY ACT 2008 WATER SERVICES INDUSTRY (PLANNING, DESIGN AND CONSTRUCTION OF SEWERAGE SYSTEM AND SEPTIC TANK) RULES 2013 APPLICATION FOR SEWERAGE WORKSISEPTIC TANK WORKS* DESIGN APPROVAL Date: 20, To: Sewerage Certifying Agency 1 hereby apply for the approval of the design to undertake the following sewerage works/seplic tank works" laration by Competent Person hereby declare and confirm in accordance with the Stalutory Declaration Act 1960 that details in this form and all documents attached fe complete, true and accurate. | further declare that the sewerage planning has been prepared in pursuant lo the Water Services Industry (Planning, Design And Construction Of Sewerage System And Septic Tank) Rules 2018, Signature of Competent Person Name of Competent Person (in block tetters) LG.No. Address: Telephone No. Fax No. E-mail addross‘Type of payment : **Bank Draft/Government Cheque Issuing Bank Date Amount Cheque no. Validity Notes: “ * Not applicabie for septic tank < § PE and connection ¢ 10 PE delete whore appropriate FORM WSIAIPDC/2 FOR OFFICIAL USE ONLY Receipt No Reference No.