FORM WSIA/PDC/1

WATER SERVICES INDUSTRY ACT 2006

WATER SERVICES INDUSTRY (PLANNING, DESIGN AND CONSTRUCTION OFSEWERAGE

SYSTEM AND SEPTIC TANKS) RULES 2013

APPLICATION FOR SEWERAGE PLANNING APPROVAL

Date :12 – 09 -2019

To: Sewerage Certifying Agency

I/ We ALPINE FARM SDN. BHD.

hereby apply for the approval of the Sewerage Planning to undertake the following sewerage works/septic tank
works*:
PERMOHONAN KEBENARAN MERANCANG DI BAWAH SUBSEKSYEN 21(1) AKTA PERANCANG
BANDAR DAN DESA 1976 (AKTA 172) SECARA PENYERAHAN BALIK DAN PEMBERIMILIKAN
SEMULA DI BAWAH SEKSYEN 204D KANUN TANAH NEGARA 1965 (AKTA 56) UNTUK CADANGAN
6 UNIT RUMAH KEDAI 3 TINGKAT BERSERTA STESEN MINYAK SEDIADA DI ATAS HAKMILIK TANAH
PN 16373 LOT 5626, MUKIM ULU TELOM, DAERAH CAMERON HIGHLANDS, PAHANG DARUL
MAKMUR. Details of Land
Address of site or premises:
HAKMILIK TANAH GM 617 LOT 5062, MUKIM HULU TELOM, DAERAH CAMERON HIGHLANDS,
PAHANG DARUL MAKMUR.
Lot No. of land occupied by sewerage works: -
Area of land occupied by sewerage works:
a) Sewage Treatment Plant _____________-_______hectares
b) Pumping Station _______-_____________hectares

Details of Population Equivalent (PE)

TYPE TOTAL PE REMARKS
RESIDENTIAL
COMMERCIAL 103.2 Refer Engineering Report for PE calculation
INSTITUTIONAL
INDUSTRIAL
OTHERS
TOTAL, PE
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Declaration by Qualified person

I hereby certify that the details in this form and all documents attached are complete and accurate. I further
certify that the sewerage planning has been prepared in pursuant to the Water Services Industry (Planning,
Design And Construction Of Sewerge System And Septic Tank) Rules 2013

Signature of competent Person

Name of Qualified Person (in Block letters): IR POO CHOON BENG

I.C. No.: 770330-08-7171

Address: Block A-2-8, Megan Phoenix, Jalan 2/142A, KM10,

Off Jalan Cheras, 56000 Kuala Lumpur, W.P.

Telephone No.: 012-3758080

Fax No.:

Email address :poochoonbeng@gmail.com

Fee details:

Type of payment: **Banker Cheque/Coverment Cheque

Issuing Bank :

Date :

Amount :

Cheque no. :

Validity :
(Note.** delete where appropriate)

FOR OFFICIAL USE ONLY

Receipt No:

Reference No.:
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Declaration by Owner

I ______________________________ the owner of the land where the sewerage works/septic tank works* will
be carried hereby agree for said works to be carried out the land

_________________________
Signature of Owner

Name of Owner
(in block letters) Tang Song Leong Tang Song Yeoh,

I.C. No /Passport No. : (MY KAD : 720916-06-5329) (MY KAD : 710814-08-5741)

Telephone No. :
Fax No. :
Email :

Declaration by Developer

I hereby declare that the information given are complete, true and accurate and this project/development
carried out in strict compliance with the Water Services Industry Act 2006 and its subsidiary
accept full responsibility to ensure all relevant works shall be completed accordingly.

_________________________
Signature of developer

Name of Developer
(in block letters) Tang Song Leong Tang Song Yeoh

I.C. No /Passport No. (MY KAD : 720916-06-5329) (MY KAD : 710814-08-5741)

Address ALPINE FARM SDN. BHD.
No. 10, Tingkat 1, Persiaran 2, Taman Tringkap,
39100 Tringkap, Cameron Highlands,
Pahang Darul Makmur.