Please ensure you have read our guidance notes before completing this application form and include as much information as possible. If mandatory fields (marked with a ) are not completed this could result in your application being returned. 1. Applicants Details Company Name Contact Name House Number/Name Contact Telephone Number(s) E-mail address 2. Name and address of agent (if any) Company Name Contact Name House Number/Name Contact Telephone Number(s) E-mail address
3. Development details What is the nature of your proposal? Name of development House Number/Name/Plots National Grid Reference e.g. ST123456 4. Planning Approval Is the development planning exempt? Yes No If Yes, please state why Planning Approval Reference If Planning Permission is required for your development, please supply the Planning Approval Reference Number(s) 5. Requisition details A public sewer Yes No A lateral drain or drains Yes No Foul Yes No Surface water Yes No
6. Use of premises Please supply the information requested below by indicating the types of development and number of properties. If you have completed any of these boxes you must supply calculations showing the quantity of domestic flows generated. If you intend to discharge any industrial waste, you must apply to us for permission to discharge and obtain a Trade Effluent discharge consent. Number of properties/square Meterage Domestic Flow (if applicable) Housing Agricultural Commercial Industrial Temporary Building Trade Effluent Other If Other, please specify 7. Previous use of land What was the previous use of the development? What is the current use of the development? Is the new water supply required for a development on a Brownfield site? Yes No Has the site or any adjacent sites or other land through which you propose to lay your water pipe(s) potentially be affected by contamination? Yes No Are you planning to store any chemicals, fuel or other materials likely to affect the quality of wholesome water and which will affect the proposed pipe selection? Yes No Brown Field Site - Construction of new properties or renovations/conversions of existing buildings, land or premises that have previously been used or developed and may be vacant or derelict Brown Field Site - Construction of new properties or renovations/conversions of existing buildings, land or premises that have previously been used or developed and may be vacant or derelict
8. Land interest What is your interest in the land to be served by the requisitioned main? Owner Occupier Local Authority Hold an option to buy 9. Discharge of flow Do you intend to discharge any flow which is not for domestic sewerage purposes? Yes No If Yes, please specify 10. Surface water If you are requisitioning a surface water sewer, you must complete the next 3 sections; surface water, highway drainage and what impermeable areas of the proposed development. We advise and recommend that you obtain the following consents, as this may prevent us from complying with the Notice and providing a requisitioned sewer or lateral drain. Has permission been formally granted for the discharge of surface water into a water course from: Environment Agency Yes No Riparian Landowner(s) Yes No Land Drainage Authority Yes No 11. Highway drainage Please explain how you intend to dispose of any new highway drainage? 12. Impermeable areas of the proposed development Highway (carriageway, footway, verge) Field to state HA i.e. Hectares Domestic (roofs, drives, paths, patios) Field to state HA i.e. Hectares
Legal Notice Legal Notice - This application constitutes a notice under Sections 98-101 of the Water Industry Act 1991 Signed Print Name Date