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Water Supply Connection Application Form |
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FORM W/S |
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(See sub-rule (1) of rule-3)
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Application Form-I |
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GOVERNMENT OF SIKKIM
WATER SECURITY & PUBLIC HEALTH ENGINEERING
DEPARTMENT
REVENUE CELL
Water Supply Connection Application Form: |
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To :
The Divisional Engineer
Revenue Cell,
Water Security & Public Health Engineering
Department,
Government of Sikkim
Gangtok
No. :
.. |
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Dated :
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Sir,
I / We request for your kind permission to allow
one water supply line from State Government main
(s).
I / We shall abide by the standing rules /
regulation and directives as may be applicable. |
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Yours faithfully,
(Signature & Seal of the Applicant) |
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( To be filled-in in capital
leters) |
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1. Name / Designation of the applicant :
.. |
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2. Fathers Name :
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3. Correct mailing address :
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..
Tel : |
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4. Detail address of Premises /
Location where connection is sought
.
..
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5. No. of Connection in the same premises
(if any)
a. Con. No.
Name
Relation
..
b. Con. No.
. Name
. Relation
.
c. Con. No.
. Name
.. Relation
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d. Con. No
. Name
..
Relation
. |
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6. Water is required for ( Tick Mark) |
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a. Drinking |
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b. Construction |
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c. Factory use |
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d. Institution |
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e. Commercials |
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7. Water is required for ( Tick Mark) |
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a. State Government 
Name of Bldg
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b. Central Government
Name of Bldg
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c. Private & Other
Name of Bldg
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8. Detail of premises ( Tick Mark) |
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a. R.C.C
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b. Non R.C.C
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c. Nos. of Storeys
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9. Period of water Supply requirement ( Tick
Mark) |
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a. Permanent
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b. Temporary
Duration in months
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10. Users details : |
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a. 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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b. Nos. of Rooms if the premises is a Hotel
/ Lodge :
Nos.
c. Nos. of Taps in the Premises :
Nos.
d. Nos. of Toilets / Water Closets in the
Premises :
Nos. |
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1) I / We hereby certify that
the above information and data provided are true
to the best on my / our knowledge and any
subsequent that taken place or contemplated so
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 1986
and the Sikkim Water Supply Rule 1990 water
connection to my premises may be disconnected in
the event I violate any rule of regulation of
the Local Self Government, Urban Development and
Housing Department, Municipal Corporation or
that of Public Health Engineering Department and
/ or fail to pay water tax / Charges or Sewerage
Tax / Charges ( as may be required under the
prescribed Act 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 water 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 on 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. BR Receipt for Rs. 10/- towards the cost
of application form :
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BR. No.
.. Date
Rs. 10/- |
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Signature & Seal of the
Applicant |
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For Office use only |
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Premises has been inspected.
This is certified that the above information
given in application is complete and correct.
Therefore, site plan prepared and the connection
proposed to connect in the distribution box no. |
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.. location at
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For approval of Divisional Engineer, please. |
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J. E. in charge
Assistant Engineer ( Rev)
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Approved / Not Approved |
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Divisional Engineer
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Certified that : |
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1. Consumer paid the New Connection fees Rs.
................................... vide
BR No.
Dated.
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2. The line form the premises
of consumer to the distribution box is
completely laid under groung as per the
direction and norms of the Government under the
supervision of concern JE. |
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3. Line will be connected to
the distribution box no.
. Connection
point no.
.. as per the approval above.
4. Monthly assesment is evaluated to Rs........................../
per month for .............
No.
of Taps as per the Tariff Rules and norms of the
Government |
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5. Work is successfully completed. |
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Permission may be granted to connect the
consumer line in the department W / S
distribution main. |
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J. E. in charge
Assistant Engineer
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Permitted / Not permitted |
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Divisional Engineer
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The consumer pipeline has
been connected to the distribution main &
consumer no.
. Bill distribution Zone
No.
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Revenue Clerk
Junior Engineer
Assistant Engineer ( Revenue)
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