FORM XI APPLICATION FORM FOR REGULARISATION OF SEWERAGE CONNECTION PLOT NO/SITE NO__________________ SECTOR/PHASE ________ SIZE ___________ RESIDENTIAL/COMMERCIAL/INDUSTRIAL/INSTITUTIONAL (Tick mark whichever is applicable) 1. NAME OF ALLOTTEE: 2. NAME OF GPA/SUB GPA/SPECIAL POWER OF ATTORNEY OF ALLOTTEE (if applicant is GPA/Sub GPA/SPA) 3. NAME OF FATHER/HUSBAND (of allottee) 4. PERMANENT ADDRESS (of allottee) (TELEPHONE NO.) DATE: SIGNATURE Name____________________ (in capital letters) The text and format of this form can be changed any time with the change in policy matters. LIST OF DOCUMENTS TO BE SUBMITTED BY THE APPLICANT i. Plumber Certificate, in the prescribed form attached. ii. Copy of sanctioned plan. iii. Proof of ownership (Allotment/re-allotment/transfer of ownership letter) iv. Attested copy of GPA/SPA (where applicable). v. Fee for regularisation Rs. 1000/-. vi. Security Rs. 100/- vii. Road cut-fee : Rates of Road Cuts (Subject to Revision) a. 30' wide road = Rs. 800/- b. 2. 45' wide road = Rs. 1100/- c. 3. 60' wide road = Rs. 1600/- d. 4. 80' wide road = Rs. 2000/- PLUMBER CERTIFICATE It is certified that the internal sewer of House No./Plot No. _______________________ Sector/Phase _______________ Urban Estate _______________ belonging to Sh./Smt. ____________________________has been connected with the main sewer & is in order of discrepancy, if any is as under : Signature of the Plumber With seal Note: This certificate may be given by any plumber registered with PUDA. The list of plumbers is available in the office & also at water works site. FOR OFFICE USE Application of Sh./Smt. _________________________ for regularization of Sewerage connection in respect of Plot/Site No. ______________________ Sector/Phase _________ has been checked and documents at Sr.No. ____________________ have been received. Payment of Rs. _______ide receipt No. _______________ has also been received. Signature of Diary Clerk Date______________ ACKNOWLEDGEMENT SLIP Application received from Sh./Smt. ___________________________ GPA/Sub GPA/SPA (if applicable) of Sh./Smt. _________________________ in respect of Plot/Site/House No. __________________ Sector/Phase ____________ has been received for regularization of Sewerage Connection on (date) _________ Diary No. _________ Payment of Rs. ________ vide Receipt No. ________________ has also been received. The applicant may contact the Divisional Engineer (Public Health) on (date) ______________ to collect the letter otherwise the letter will be despatched by post on (date) ______________. Signature of Diary Clerk
