Republic of the Philippines

Department of the Interior and Local Government

[Address of DILG Regional Office]

(FOR WATER SUPPLY SYSTEM)

Region: __X____________________________________________________________________
Province: __MIS. OR.____________________________________________________________
Municipality: __GINGOOG CITY____________________________________________________
Proponent Brgy.: BARANGAY BANTAAWAN__________________________________________
Project Title: ___________________________________________________________________
Project Description: ______________________________________________________________
Estimated Project Cost: ___________________________________________________________

A. TECHNICAL REQUIREMENTS:

I. TYPE OF WATER SOURCE

SPRING WELL (Dugwell, Shallow, Deepwell)

If SPRING, provide the following information:

Location of the Spring: Dumpilayan

Elevation Difference of Source to the Service Area (1,420 – 681) 739 meters (Brgy. Hall)
Distance of Spring Source to the Service Area: 4.60 KM. (Brgy. Hall)
Water Discharge Flow (Q): 0.926 lps (plus)

If WELL, provide the following information:

Location of the Well:

Elevation Difference of Source to the Service Area
Distance of Well Source to the Service Area:

IS THERE A GEO-RESISTIVITY STUDY CONDUCTED?

YES NO

IF YES: Get a copy of the report.

IF NO: Check the existing well in the area, and get the information e.g. when
constructed, who is the implementing agency, depth of the well and
other information about the well if any.
 II. QUALITY OF WATER:

POTABLE NOT POTABLE

If NOT POTABLE: Provide treatment facility in the design.

III. DISTANCE OF WATER SOURCE TO THE NEAREST CONSTRUCTED SEPTIC TANK:

Minimum of 25 meters away from the septic tank.

B. NON-TECHNICAL REQUIREMENTS:

I. IS THERE A LAND OWNERSHIP ISSUE?

YES NO - Forestal

IF NO: Kindly attach proof of acquisition (e.g. Deed of Donation)

IF YES: Kindly specify the area with land ownership issue.

How long to secure land ownership?

II. IS THERE PROJECT NOT LOCATED IN A NON-BUILD ZONE?

YES NO

IF NO: Change the location of the water supply structure affected (e.g location
tank [must be within the proponent barangay])

IF YES: Apply for MGB Certification.

III. IS THE PROJECT NOT LOCATED IN THE HAZARD ZONE?

YES NO

IF NO: Ensure that engineering mitigation is included in the DED to counter the
identified hazard.

IF YES: Apply for MGB Certification.

IV. AVAILABILITY OF ELECTRICITY

YES NO

IF NO: Include the estimated additional cost for the provision of electricity.
Evaluated by:

___________________________ ___________________________
Name and Position Name and Position

___________________________ ___________________________
Name and Position Name and Position

Approved by:

___________________________
DILG Provincial Director