Fillable CONNECTION TO COUNCIL SERVICES APPLICANT (Queenstown Lakes District Council New Zealand)

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CONNECTION TO COUNCIL SERVICES APPLICANT (Queenstown Lakes District Council New Zealand)

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Licence to Occupy Y / N:
Building Consent #:Resource Consent #:
APPLICANT
Name of Property Owner:
Contact Person / All trustee names:
Valuation Number:
APPLICANT DETAILS
Phone Numbers: Day Mobile:
Email Address:
Postal Address: Post code:
DETAILS OF SITE // Location of site to be serviced
CORRESPONDENCE DETAILS // If dierent than above applicant details – E.g. consultant, agent or architect
Address / Location to which this application relates:
Name & Company:
Phone Numbers: Day Mobile:
Email Address:
Our preferred methods of corresponding with you are by email and phone.
The decision will be sent to the Correspondence Details via email.
Legal Description: Can be found on the Computer Freehold Register or Rates Notice – e.g Lot x DPxxx (or valuation number)
Page 1/4 // October 2017
CONNECTION TO
COUNCIL SERVICES
NATURE OF CONNECTION TO SERVICE REQUIRED
STA
NDARD CONDITIONS FOR ALL APPLICATIONS
A
• No work shall proceed until the applicant is in receipt of approved application.
• The work shall be carried out by a Contractor approved by the Queenstown Lakes District Council
• The cost of restoration of services or property damaged during the course of the work shall be the responsibility of the
applicant.
• The applicant shall be responsible for contacting the appropriate Utility Operator and arranging for the location of any
underground services in the proposed work area.
• The applicant shall arrange to reinstate all Council Road and Footpath services, where applicable, to the Council’s satisfaction
at the applicants own cost and shall advise the Council in writing of the date this restoration work is complete.
• Materials, equipment and method of construction shall be to Council’s standards applicable at the time of application.
• The applicant shall be solely responsible for the adequacy of all restoration works for a period of twelve months following their
completion.
• As built plans are required at the time of inspection.
New Replacement Temporary Diameter Diameter of
Connection of Main Connection
requested
Water Supply ___________________ ___________________ refer A & B
Stormwater ___________________ ___________________ refer A & D
Sewer ___________________ ___________________ refer A & C
Vehicle Crossing ___________________ ___________________ refer A & E
Further Information to assist processing:
The initial fee payable with this application is $280 for the rst connection to council services and $120 for each additional
connection.
E.g application for vehicle crossing and sewer connections is $280 + $120 = $400 total.
• Initial fees are based on expected processing time and one site visit, providing clear detailed information is submitted by the
applicant.
• Return inspections because of non-complying initial inspections may be additionally billed to the owner/applicant named above
based on time taken.
INITIAL FEE INFORMATION
PAYMENT // An initial fee must be paid prior to or at the time of the application and proof of payment submitted.
I conrm payment by: Bank transfer to account 02 0948 0002000 00 reference CCS# and Street Address
(If paying from overseas swiftcode – BKNZNZ22)
Cheque payable to Queenstown Lakes District Council attached
Manual Payment at reception
Fee Required:
Fees as per Resource Consent & Engineering Fees & Other Charges
http://www.qldc.govt.nz/planning/resource-consents/application-forms/
Date of Payment:
Reference Used:
Page 2/4 // October 2017
WATER SUPPLY CONNECTION
B
PIPED SEWER CONNECTION
C
STORMWATER CONNECTION
D
VEHICLE CROSSING APPLICATION
E
• An Acuo® CM2000 (GM900 tobies to be used in Queenstown and Wanaka due to algae issues) with AMB003 and AMB350
valve box combination or other prior approved toby valve and box shall be brought to ground level as close as practicable to
the boundary.
• An Elster PSM V100 or Sensus 620 water meter shall be installed on to the Acuo manifold. Wanaka and Queenstown only -
water meters shall be provided to Council’s maintenance contractor Veolia.
• If water supply is intended for irrigation or pool/spa water supply please contact Council for special requirements.
• Minimum depth of service shall be 600mm at any point within the road corridor, unless approved special protection is
provided.
• The Council’s water mains shall only be turned o by the Council’s maintenance contractor and is subject to an additional
charge (72 HOURS NOTICE REQUIRED). It is an oence to introduce contaminants into Council’s potable water system.
• An approved cleaning eye brought to ground level shall be provided on the property as close as practicable to the boundary.
• The property owner is responsible for the cost of clearing all future blockages that may occur between the property boundary
and the sewer main.
• Minimum cover to service shall be 750mm at any point within the road corridor unless approved special protection is provided.
• It is the property owners’ responsibility to ensure that only sewage enters the sewerage system. It is an oence to dispose of
stormwater though a sewerage drain.
• An approved sump shall be provided on the property as close as practicable to the boundary where:
• Drains serve more than 2 residential dwelling units
• Drains serve commercial or industrial premises
• Drains receive yard or subsoil drainage
• It is the property owners’ responsibility to ensure that only stormwater enters the drainage system. It is an oence to dispose of
sewage or sullage water through a stormwater drain.
• Minimum cover to service shall be 750mm within the road corridor.
• A site plan is required to be submitted with the application showing:
• Dimensions of crossing requested (including construction details) from edge of existing carriageway to the property
boundary
• The design of any vehicle crossing shall be in accordance with Section 14 and Appendix 7 of the District Plan
• Location of crossing in relation to site boundaries and existing intersections
• Speed limit of roads
• Any structures required within road reserve including retaining walls
• Surfacing material proposed
• Location of water take (ideally hydrant ‘Unitid’ from GIS and a screen shot of locality)
• Volume for each ll
• Number of lls per day
• Max ow rate
• Backow prevention method to be applied and if it is certied/inspected
• Trac Management Plan or justication of why it is not required
TEMPORARY CONNECTION
F
Page 3/4 // October 2017
The applicant shall provide a site plan which shall clearly show the location and position of proposed connection(s) and depth
required below ground level at the property boundary. Also state size of connection required.
Should approval be granted for the above, I agree to abide by the conditions of the approval listed on the reverse of this form. I also
agree that no work shall proceed until I am in receipt of the approved application.
Development Contributions may be calculated as a result of this application for increased demand placed upon Council
Infrastructure. These will be calculated and invoiced to the owner. Connection to any Council Service cannot be made until any
Development Contribution has been paid.
Be aware that this application may trigger the need for a Road Opening Notice. Any approval letter will advise you in this regard.
Please send your completed application to: engineeringacceptance@qldc.govt.nz
FOR OFFICE USE ONLY - QLDC to complete
Fees Payable: Initial Connection: $280
Additional Connections: _______ @ $120 = _______________ Sighted: _____________________________________________
Total Deposit: $ ________________________________________ Comments if new connection: ___________________________
Receipt No: ___________________________________________ Application Approved: _________________________________
Application Approved by: _______________________________ Date: _______________________________________________
Date: ________________________________________________
Signed on behalf Queenstown Lakes District Council
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: engineeringacceptance@qldc.govt.nz
www.qldc.govt.nz
Page 4/4 // October 2017
APPLICATION & DECLARATION
The Council relies on the information contained in this application being complete and accurate. The Applicant must take all reasonable
steps to ensure that it is complete and accurate and accepts responsibility for information in this application being so.
If lodging this application as the Applicant:
I/we hereby represent and warrant that I am/we are aware of all of my/our obligations arising under
this application including, in particular but without limitation, my/our obligation to pay all fees and
administrative charges (including debt recovery and legal expenses) payable under this application as
referred to the Fees Information section.
If lodging this application as agent of the Applicant:
I/we hereby represent and warrant that I am/we are authorised to act as agent of the Applicant in
respect of the completion and lodging of this application and that the Applicant is aware of all of his/
her/its obligations arising under this application including, in particular but without limitation, his/her/
its obligation to pay all fees and administrative charges (including debt recovery and legal expenses)
payable under this application as referred to the Fees Information section.
Signed (by or as authorised agent of the Applicant) **
Full name of person lodging this form
Firm/Company Dated
**If this form is being completed on-line you will not be able, or required, to sign this form and the on-line lodgement will be treated as
conrmation of your acknowledgement and acceptance of the above responsibilities and liabilities and that you have made the above
representations, warranties and certication.
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CONNECTION TO COUNCIL SERVICES APPLICANT (Queenstown Lakes District Council New Zealand)

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Completed 20 January 2021

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