Application for Piped
Services Connection
This form relates to new water, stormwater or wastewater connections to
the Council mains. Please complete all relevant details.
*Note: There is a $185 fee associated with the water connection. No fee is associated
with the wastewater or stormwater connections.
29 Bowler Avenue, Gore 9710
PO Box 8, Gore 9740
Phone 03 209 0330
Fax 03 209 0357
Email info@goredc.govt.nz
www.goredc.govt.nz
Application for Piped Services Connection
1
Applicant/Agent(s) Name:
Applicant/Agent(s) Address:
Owners Name:
Occupier Name (if different from owner):
Physical Address of affected property:
Telephone (day): Mobile:
Name and contact details of registered plumber
Name: Registration No.
Address:
Telephone: Mobile:
Name and contact details of registered drain layer (if different from above)
Name: Registration No.
Address:
Telephone: Mobile:
This application is in regard to the following Infrastructure
Wastewater (Section A) Stormwater (Section B)
Potable Water Supply (Section C)
Wastewater connection – Connection completed by registered Plumber/Drainlayer
Material & Diameter:
Estimated date of Completion:
Stormwater connection – Connection completed by registered Plumber/Drainlayer
Material & Diameter:
Connection type: (kerb & channel or to stormwater main
Estimated date of Completion:
Urban water supply connection – Completed by Council Staff only
Reason for application Commercial
New Dwelling Industrial
Existing Dwelling Other (please state):
I require the Council to supply the boundary manifold (toby) and manifold box (this is an additional cost)
Material & Diameter of connection:
Date Connection Required: (GDC staff to attend site -
min 5 working day’s notice
)
Specific information for applicants
GDC staff are responsible for completing the tapping and connection to the water main only. Any extra
work or fittings required will be charged accordingly.
Any additional fittings and labour required by Council staff to complete the job, other than the actual
water main connection, will be invoiced to the applicant upon completion of the work.
Urban Supply: All fittings used from the water main to the manifold shall be installed to the Councils
approved standard. Any existing redundant service lines must be disconnected at this time.
A minimum of five working day’s notice is required before proposed work is to begin on site.
Extraordinary water users shall be required to install an approved water meter. Extraordinary is defined
by the Water Supply Bylaw 2010
This application may result in the property being liable for financial contributions for water and/or
wastewater.
Office Use Only Receipt number:
Water application fee paid: Y N Amount paid:
Officer Initials: Date:
Application for Piped Services Connection
2
As-built diagram of connection (Please draw in the space provided below)
Application for Piped Services Connection 3
Please show distances from:
Pipework
Bounderies
Footpath
Road
Depth
Toby Location
As shown in the example drawing (left)
EXAMPLE DRAWING - not to scale
3 Waters Field Staff
Fittings and pipework installed correctly?
Yes Field sheet filled in
No Parts recorded
Diagram drawn
Water Meter Info Meter Serial Number
Pipe Diameter
Initial Meter Reading
Comments:
Connection completed and checked by: Date:
Assets section
Water meter required? Yes No Wastewater connection? Yes No
Backflow preventer? Yes No Stormwater connection? Yes No
Road opening permit? Yes No
OFFICE DATE INITIAL COMMENT
Assets Officer
Check complete
Water Connection Fees paid N/A
Approve connection
Create CRM for water connection N/A
Date connection required
Wastewater or Stormwater Connection Building
Consent No:
3 Waters Field Staff
Received
Completed
As built complete
Application for Piped Services Connection 4
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