FORM NO. X APPLICATION FORM FOR SANCTION 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.) 5. CORRESPONDENCE ADDRESS (Telephone No.) 6. DATE OF SANCTION OF BUILDING PLAN 7. WHETHER THE BUILDING IS: COMPLETELY PARTIALLY (Tick mark whichever is applicable) CONSTRUCTED CONSTRUCTED 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 Architect certificate regarding completion of construction, in prescribed form attached. iii Attested copy of GPA/SPA (where applicable) iv Proof of ownership (allotment/re-allotment/transfer of ownership letter) v Copy of Sanctioned plan. vi Security of Rs. 100/- vii Road Out-rates (Subject to Revision) a. 30' wide road = Rs. 800/- b. 45' wide road = Rs. 1100/- c. 60' wide road = Rs. 1600/- d. 80' wide road = Rs. 2000/- PLUMBER CERTIFICATE NAME OF PLUMBER: _______________________________ LICENCE NO. _______________________________ ADDRESS OF THE PLUMBER _______________________________ It is certified that the internal fittings of Water Supply and Sanitary installations in house No. __________________________ Sector/Phase ____________________ Urban Estate ________________ belonging to Sh./Smt. _______________________ have been done under my supervision and according to by laws of PUDA _________________and as per sanctioned plan. 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 sanction 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. _______ have been received vide receipt No. _______________ dated _____________. Signature of Diary Clerk Date______________ ACKNOWLEDGEMENT SLIP Application received from Sh./Smt. __________________________________ OPA/Sub OPA/SPA (if applicable) of Sh./Smt. ______________________________ in respect of Plot/Site/House No. __________________ Sector/Phase______ ____________ has been received for sanction of Sewerage Connection on (dated) _________________ Diary No. _________ Payment of Rs. ________ vide Receipt No. ________________ has also been received. The applicant may contact the Divisional Engineer (Public Health) on (date) ______________ at the point to collect the letter otherwise be dispatched by post on (date) ______________. Signature of Diary Clerk
