DQ yy ccomrreeves sermon | SY RHR APPLICATION FOR POINT OF STORMWATER DISCHARGE FOR DRAINAGE/ASSET INFORMATION TO BUILD OVER EASEMENT Peace prin clearly black pen and read all notes on the application form before completing WHAT IS REQUIRED? | cHare Point of Dischargo | $64.00 Underground Drainage Pipe Information (Council drains only) 00.00 ‘Special Asset information (Please detail below) [$60.00 Consent to build over easement (Details of proposal to be attached) $66.00 ‘APPLICANTIOWNER’S NAME. POSTAL ADDRESS Post Code TELEPHONE NO's. BH AH OTHER CONTACT DETAILS Fax No: Email Address: PROPERTY DETAILS (property address for which you are seeking information) Lot No: Plan No: [ Street No: Street Name: | Township: ‘SPECIAL ASSET INFORMATION What specific information are you requesting? (An addtional fee may apply depending on the typeof information required) PLEASE REFER TO FEE STRUCTURE ABOVE FOR APPLICABLE FEES Method of Payment 0 Cash _o CreditCard 0 On Account —_oChequeNo: © Other | Card Type © MasterCard Card No: Signatui BH essen compete opliton fm wih your ew he inasrcre Deparment athe aes below Information Privacy Declaration Coun is collecting the information an ths form so that it may consider your application in accordance with is legislative powers and functions and it wil only be disclosed in accordance with these powers and functions. You may access the information by contacting Cour For Office Use Only Fee Recoived Yor No] Cashier's Quick Codes Build over easement 038 | Date Fee Received Legal point of discharge os | Underground drainage ox | Receiot No Special Asset Information ox7_| Date Appiaton Received Fie No Responsible Ofcer(s) _ a Private Bag 1000 Rosebud 3939 Phone 1300 850 600 Fax 03 5986 6696 Email: cust@mornpen.vic.gov.au Web site www.mornpen.vic.gov.au oc 10.A5585195(Upded zane72017)