Fillable Application for Trade Waste Discharge Appendix A RURAL (Gore District Council New Zealand)

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Application for Trade Waste Discharge Appendix A RURAL (Gore District Council New Zealand)

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Trade Waste Bylaw 2016
Application for
Trade Waste Discharge
Appendix A
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 Trade Waste Discharge - Appendix A
1
Trade name and street address of trade premises
Name of premises:
Physical address:
Postal address:
Email:
Telephone (day): Mobile:
Telephone (after hours): Fax:
Owner details and postal address of customer for charging
Name of owner of premises:
Postal address:
Email:
Telephone (day): Mobile:
Telephone (after hours): Fax:
RURAL CITY LIVING
Contact details for further enquiries
Name of owner of premises:
Postal address:
Email:
Telephone (day): Mobile:
Telephone (after hours): Fax:
Term of consent sought
From (date):
1 year 2 years 5 years Other
Legal Description
Valuation Number:
Lot: DP:
Section: Block:
Survey District:
This application relates to
Proposed new discharge
An existing discharge for which no consent exists
Current point or place of discharge:
Renewal of a consent
Variation to an existing consent
Nature of variation:
Use and attach additional sheets as required
Are the premises already connected to the public sewer?
Yes No
Are the domestic and trade waste streams separated
Yes No
Application for Trade Waste Discharge - Appendix A 2
Number of connections required
Size: No:
Size: No:
Note: minimum size is 100mm.
Description of main trade activity
Declaration
I am duly authorised to make this application and I believe the information contained in this
application is true and correct.
Full Name:
Position:
Signature: Date:
Application for Trade Waste Discharge - Appendix A 3
First Point of Contact:
Owner Applicant
Consent posted to:
Owner Applicant
Application Fee $
Other $
GST $
Total Fee payable $
Receipt Number:
Cash/Chq/ Eftpos/ EB
Building Consent Number:
File No:
DVR No:
Trade Waste Consent approved by:
Name:
Officers Signature:
Position:
Date:
Application for Trade Waste Discharge - Appendix A 4
FOR OFFICE USE ONLY
Diagram for connection location
(Show distances from boundaries, kerbs, buildings etc)
Important Note: If you have any questions about completing the information contained in this application form, please
phone 03 209 0330 and ask for the Council’s 3 Waters Department.
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Application for Trade Waste Discharge Appendix A RURAL (Gore District Council New Zealand)

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Completed 15 November 2020

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