Application Form for Water Supply/ Sewerage Connection (Urban)

Name of the AppHcant:
Father's I Husband's Name:
Permanent Address:
Address of premises for which
Connection Applied:
Type of Connection Applied:
(Domestic/ Commercial/ Industrial/ Institutional)
Size of Ferrule for Water Connection
applied:
(6mm/10mm/ 12mm/15mm/20mm)
In case of Institutional/ Industrial/
Commercial connection quantity and na ure
of Sewerage to be disposed in Sewer:
(70% of the water consumed)
Proof of Residence I Identity Attached: Photostat Copy of Ration Card N orer Identity Card
Details of Connections:
(if held by the applicant previously)
Details of Fee Deposited for Road-Cut:
(if appHcable)
a) Certified that I am owner of the premises I building for which connection is applied.
b) Certified that the information given in the Performa above is correct. If at any stage,
any of above information is found wrong I will loose the right of continuing my
connection and liable of the punishment as per rules of the department in force at the
time.
c) I agree to abide by the rules and regulations of the department in force from time to
time.
Signatore of the applicant
Report of the fitter I authorized person of the Department
The existing Water Supply I Sewerage line is of size .................. mm and is ............... .
meters away from house of the applicant. Road . . . . . . . . . . . . . . . . meters wide requires to cut for
giving connection.
Signature
Name and Designation of Reporting Officer
Recommendation of the Junior Engineer
Ferrule connection of ............ mm size from existing W/S line ........... ... mml Sewerage
connection in Manhole/ Oblique connection in ................ mm sewer line recommended.
Date: Signature
(Full Name of the Junior Engineer)
As recommended above ............ mm ferrule connection I Sewer connection sanctioned.
Sub Divisional Engineer
Public Health Engineering Sub Division
Received a sum of Rs ......................... vide Receipt No .................... dated ................. .
on ale of security/ connection fee charges. Entered in register page no ........................... The
account no. of the consumer is .................................... .
Sub Divisional Engineer
Public Health Engineering Sub Division