APPLICATION FOR PRIVATE WATER CONNECTION IN URBAN AREA
To
The SDE
Public Health Engineering Sub-Division
Sub Division No………….
Sir,
I need a metered private water connection from your distribution system into house no. ………………Situated near……………
1. The house is owned /not owned by me.
2. I undertake to act in accordance with the bye laws and regulations made by the department from time to time. I will not fix any hand pump and tap or pumping set on the supply main.
3. I agree that the PHED, without notice will have the power to disconnect the service pipe up to my premises, if it is considered fit, advisable and necessary to do so for any reason whatsoever.
4. I will provide all material and labour also and will pay the department, the required charges and also under take to pay the monthly consumption charges regularly.
Yours faithfully
Dated ………………..
Signature of applicant
In case of tenant
I, the owner of the house No……………………. shall be responsible for all payments due against the private water connection. In case of non payment by the tenant, I have no objection giving in a connection to the said house.
House Owner’s Signature
Application Form for Water Supply/ Sewerage Connection (Urban)
Name of the Applicant:
Father’s / 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 nature
of Sewerage to be disposed in Sewer:
(70% of the water consumed)
Proof of Residence / Identity Attached:
Details of Connections:
(if held by the applicant previously)
Details of Fee Deposited for Road-Cut:
(if applicable)
Photostat Copy of Ration Card /Voter Identity Card
a)
b)
c)
Certified that I am owner of the premises / building for which connection is applied.
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.
I agree to abide by the rules and regulations of the department in force from time to time.
Signature of the applicant
Report of the fitter / authorized person of the Department
The existing Water Supply / 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 …………..mm/ 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 / Sewer connection sanctioned.
Sub Divisional Engineer
Public Health Engineering Sub Division
…………………………….
Received a sum of Rs……………………. vide Receipt No……………….. dated ……………… on a/c 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
……………………………