eee FORM Si.No. [orne = onte t |S No or ms. soy FORM FEE RS. 500/- DELHI JAL BOARD GOVT. OF NCT OF DELHI APPLICATION FORM FOR SEEKING PERMISSION FOR GROUND WATER EXTRACTION 1 Name of the applicant ‘Owner Tenant / Occupier /Othars (Please Specify) — 2 Wibkomedtheapbeent Ph. No Fax E-mail. 3, Type of establishment (Tick Mark) Residential / Commercial / Office / Hospital / Educational Institution / industrial / Othe (Please Specty) _ 4 Ownership status of land whete Téwel is proposed 5. No.of beneficiaries (im terms of No.of persons) 6. Quontity of water required (ge detais wn Kil Ltr. — 7. Prosent quantity of available water and sources of water supply (DIB pipe supply KL (ii) Wator tanker (Own Ter KL (wv) Others 8. Purpose for extraction of groune water with detail of requirement © Danking (i) Domestic i) Commerce (w) tnetastril (Others (Please specity) [] 9, Ground water qualty in and around the area. Ie t potabie or hard? = Coma,40, tt. 2 1% 14 18. FORM SL. No. ‘Are there any other Tiwells in the establishment? (Working _Nes. i) Abandoned_Nos. (ii) Others _ (1 Spaciyy Give details of each existing T/well in following format and attach a enclosures (including T/well for orticuture) Location | Purpose/Year of construction Dopth of drting (In meters) F Diameter (mm) Depth of ground water level (In meters) Discharge (litres / hr) Operational hours/day | Operational days/year ‘Mode of lit and Horse Power of pump Whether permission granted/ragistered with GWA, I 50 details thereot ‘No.of existing TAWells in the radius of 300m of the proposed location alongwith distance from the nearest existing bore Nos. ‘Ace the existing bore wells registered Yes or No (tyes, please attach photocopy of the registation certificate) Have you applied earlier for sanction of a bore wot Yos or No (tyes, please give detads thoreo! wth status) ‘Whether rain water harv ing system has been provides! Yes or No (@) yes, mention recharge potential and detaits of structure (©) Commissioned / functional Yes or No (2) no. mention proposed FH pen and the time timitFORM SL.No! 16. Whethor waste wator troatment plant exisis Yes or No (@) yes, the capacity and the proposed uses of the recycled water (©) Commissioned / unctional Yes or No (©) no, mention proposed action pian and the time limit. Note: PERMISSION TO INSTALL TUBE WELL WILL BE GRANTED ON MERITS OF THE REQUEST AND DECISION OF THE AUTHORITIES WILL BE FINAL AND BINDING [APPLICANTS ARE REQUIRED TO ATTACH THE FOLLOWING. (0). RECEIPT OF RS. 500/- IN CASH /DD/ PAY ORDER DRAWN IN FAVOUR OF DELHI JAL BOARD. (i) OTHER ENCLOSURE, IF ANY UNDERTAKING A. tis cortliod that particulars / information provided above are true. fully understand that af any stage i the information provided by me is found incorrect, the request / permission for boring/ re-boring of tube well will deemed to be rejected, agree to instal a water meter and will maintain monthly extraction record of water. urter alow regular ‘ground water extraction readings to be taken bythe Govt. appointed authorty List of Enet Signature ofthe Applicant (With Date) FORM SL.No. FOR OFFICE USE ONLY Received application No. From List of enclosures 1. Receipt of Ris, 500!- in cash / DD! Pay Order drawn in favour of Delhi Jal Board, 2 Other ensiosure, it any ‘Signature with Date & Seal