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Application Form – I
(Sewerage)
GOVERNMENT OF SIKKIM
WATER SECURITY AND PUBLIC HEALTH ENGINEERING
DEPARTMENT
SEWERAGE / REVENUE CELL
Sewerage Connection Application Form: |
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The Divisional Engineer, |
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Sewerage Division / Revenue |
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Water Security & Public Health Engineering
Department, |
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Government of Sikkim, Gangtok. |
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No:…………………………
Dated:…………………. |
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I / We request for your kind permission to allow
one Sewer line connection from the Government
sewer main.
I / We shall abide by the standing of
rules/regulation and directives as may be
applicable. |
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Yours faithfully |
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(Signature Seal of the
Applicant)
(To be filled-up capital letters) |
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(1) Name / Designation of the applicant:
……………………………………………………… |
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(2) Correct Mailing Address:
…………………………………………………………………….
................................................................
................................................................ |
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(3) House No: with location:
…………………………………………………………………….. |
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Tel. Phone:………………………………………………………….. |
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(4) Name of the Department or
Organization if in service :
……………………………………………………………………
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(5). Sewerage connection is
required for (Tick Mark) |
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a. Residential |
b. Temporary |
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 c.
Factory use |
   d.
Institutional |
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 e.
Commercial |
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6.Sewerage connection is required for (tick
Mark) |
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  a.
State Government |
b. Central Government |
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 c.
Private & Other |
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7. Detail of premises (Tick
Mark) |
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a. R.C.C b. |
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b. Non R.C.C |
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c. Size of Building: Length:
…………………….. Ft. width:……………………. Ft. |
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d. Nos. of storeys (Tick Mark): |
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One Storeyed |
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Two Storeyed |
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Three Storeyed |
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Four Storeyed |
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Five Storeyed |
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Six Storeyed |
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More than Six Storeyed |
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8. Period of Sewer Connection
requirement (Tick Mark) |
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  a.
Permanent |
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 b.
Temporary |
Duration in months |
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9. Users details: |
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a. Nos. of Family living in the
premises |
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    1
Family : |
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2 Families : |
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3 Families : |
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More than 3 Families : |
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Not Applicable |
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b. Estimated Average Total Nos.
of users/Family Members |
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3-5 Persons : |
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5-10 Persons : |
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10-15 Persons : |
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15- 25 Persons : |
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More than 25 persons : |
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c. Nos. of Rooms if the premises
is a Hotel / Lodge: .......... Nos. |
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d. Nos. of Toilets / Water
Closets in the Premises : ……………………… Nos. |
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1) I / We hereby certify
that the above information and date provided are
true to the best of my/ our knowledge and any
subsequent changes that take places shall be
notified to the Department immediately. |
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2) I / We hereby fully agree
that apart from other reasons prescribed in the
‘ Sikkim Water Supply and Water Tax Act, Sikkim
Sewerage & Sewerage disposal Act, Sikkim Water
Supply rule and Sikkim Sewage & Sewage Disposal
Rules water connection to my premises may be
disconnected in the event I violate any rule or
regulation of the Local Self Government, Urban
Development and Housing Department, Municipal
Corporation and or fail to any water tax/
Charges or sewerage Tax/ Charges ( as may be
required under the prescribed rules.) |
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3) I / We hereby declare that
I/We am/ are the owner(s) of the premises
mentioned in the application and entire
liability of payment of sewerage charges, tax,
dues and fines shall rest on me/us, OR on the
person whomsoever/the ownership/liability of
above premises is legally transferred. |
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Enclosures (Tick Mark): |
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a. B.P. Plan of the house (if
within UD&HD / Town or Municipal area): |
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b. Ownership Certificate / Land
property document. : |
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c. B.R Receipt for Rs. 10/-
towards the cost of application form : |
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d. One self address ed envelope
with correct amount of postal stamp affixed: |
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Signature & Seal of the
Applicant
Head of the Department
(in case of Govt. Org.) |
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FOR OFFICE USE
ONLY: |
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a. Rs. 10?- paid
vode B.R No:…………………………….. Dated:…………………………………...
(Sum to be deposited under the Account Head
‘0215’ Water Supply). |
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(Revenue Clerk)
Sewerage/Revenue Cell- WS & PHED. |
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