GOVERNMENT OF SIKKIM PUBLIC HEALTH ENGINEERING DEPARTMENT GANGTOK WATER SUPPLY CONNECTION FORM To, The Divisional Engineer, No................. Water Supply & Sewerage Division P .H .E. Department Government of Sikkim Gangtok Date.............. Sir, I/We request for your kind permission to allow to draw water from the State Government Water-Main(s). I/We shall abide by the standing rules/regulations and directives. Yours faithfully, (Signature & Seal of applicant) 1. Name of the Applicant : 2. Correct Mailing Address : 3. Name of the Department/Organisation if in service : 4. Water is required for : (a) Drinking/Construction/Factory use/Specify other uses : (b) State Government/Private/Central Govt./others : (c) Specify Residential/Commercial/Institutional & other structure details : 5. Duration of W/S requirement : (a) Permanent/Temporary/specify time if temporary : 6. Nos Family Units............ No. of users............... Nos. of taps ............. 7. Whether owner or tenant : 8. If tenant then N.O.C from owner attached or not : 9.Location where water is required : CERTIFIED THAT THE ABOVE INFORMATIONS ARE TRUE TO THE BEST OF MY/OUR KNOWLEDGE (Signature of Consumer) UNDERTAKING BY THE CONSUMER I hereby fully agree that apart from other reasons prescribed in the Water Supply Rules/Acts, my Water Supply connection shall also be disconnected in the event I violate any of the rules or regulations of the Local Self Government. 'CONSUMER'
