Application for a Disconnection
from Water/ Wastewater/
Stormwater/ Tradewaste
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email enquiries@waitomo.govt.nz, Website www.waitomo.govt.nz
Name:
Address:
Phone Work: Private:
Mobile: Fax:
1. Applicant Details
Name:
Address:
Phone Work: Private:
Mobile: Fax:
2. Owner Details (if different from Applicant)
Street Address:
Valuation Number:
Legal Description: Lot
DP
3. Details of property requiring disconnection of services
Building
Vacant Land
Front Section
Back Section
Corner Section
House
Flat
Property Type:
Industrial
Commercial
Residential
Property Use:
4. Services to be Disconnected
Water Waste Water Storm Water Tradewaste
PAYMENT IS REQUIRED PRIOR TO JOB BEING DONE
Specify the quantity of disconnections required for each service:
337805 : 003/004 : WS3
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email enquiries@waitomo.govt.nz, Website www.waitomo.govt.nz
4. Sketch Plan
Please sketch a plan of the property showing the boundaries, roads, buildings etc.
Signed:
5. Declaration
7. Ofce Use
I/We hereby agree to pay the Waitomo District Council all fees and charges as are from time to time
requested, and I/We will abide by all the bylaws and regulations of the said Council which affect the
service applied for.
Date:
6. General
Normally applications will take 30 working days to process. After the fees have been paid this form
is to be passed on to the Service Engineer.
Date Received:
Total Fee payable:
Rates adjusted for Disconnection:
Date of Processing:
Trade Waste
Trade Waste Number:
Water Usage
Ordinary Extra Ordinary - Water Meter required.
Water Meter Details
Serial Number:
Reading when installed:
Meter Size:
Engineer Comment:
Engineer Signature:
Date:
Application for a Disconnection
from Water/ Wastewater/
Stormwater/ Tradewaste
337805 : 003/004 : WS3
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