Fillable FORM PO1: Classification: NULBC PROTECT Personal THE PRIVATE (Newcastle-Under-Lyme Borough Council)

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FORM PO1: Classification: NULBC PROTECT Personal THE PRIVATE (Newcastle-Under-Lyme Borough Council)

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Classification: NULBC PROTECT Personal
FORM PO1
Classification: NULBC PROTECT Personal
Page 1 of 4
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THE PRIVATE WATER SUPPLIES REGULATIONS 2016 (as amended)
Questionnaire for Owners and Occupiers of Premises using water from a Private Water Supply
Any questions pleas
e email environmental_health@newcastle-staffs.gov.uk or call 01782
717717 and ask for Hallan Sambrooke.
Q1 Contact details
Name:
Address:
Daytime Telephone:
Email address:
Q2 Private water supply or mains
Please tell us where your primary source of water is obtained from
Private water supply (go to Q3) Mains (Severn Trent / United Utilities) *
Is the private water supply still in use?
Yes, it is used for drinking, washing and cooking etc. (go to Q3)
No, the suppl
y has been totally disconnected. (No further details will be needed).
Yes, it i
s plumbed in and operational but not used as a primary source of water.
Please explain below the purpose of its use e.g. flushing toilets, watering the garden, cattle
troughs etc. (No further details will be needed).
*Please note that this information will be verified by the water company serving your area
(Severn Trent / United Utilities).
Q3 Purpose for which
premises are used:-
Please tick whichever boxes are appropriate:
Please indicate the number of months during the last year that the premises were used for
the purpose/s
Number
of
months
Domestic residence (drinking, washing and cooking) complete Q 3.a
Commercial, business or industrial premises complete Q 3.b
Food or drink production for consumption off the premises complete Q3.c
Food registered, mobile caterer, home caterer, restaurant, pub or café complete Q3.d
Residential establishment e.g. school, hotel, hospital, residential home complete Q3.e
Holiday accommodation e.g. B&B, holiday let, camp site, caravan site, holiday-village
complete Q3.f
Water used for recreational purposes e.g. hot tub, sauna, swimming pool, complete
Q3.g
Other purpose not mentioned above complete Q3.h
Q3.a Domestic resi
dence
Number of people normally living in the property
Are you the owner of the property Yes
No
If you are not the owner, is the property rented Yes No
Premises Code
Case Ref
Classification: NULBC PROTECT Personal
FORM PO1
Classification: NULBC PROTECT Personal
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If the property is rented, state the details of the property owner/letting agent:
Name:
Address:
Tel number:
Q3.b Comm
ercial, business or industrial premises
Please state the business name and type of business:
Number of people normally working on the premises:
Number of people who work at the premises and also live onsite in a domestic residence:
Q3.c Food or drink production for consumption off the premises
Please provide details of the type of production e.g. washing vegetables/crops, dairy, brewery.
Approximate volume of water used in food process per day in previous calendar year?
Do you require a routine water test from the Council for farm assurance purposes? Yes No
Q3.d Food reg
istered, mobile caterer, home caterer, restaurant, pub or café
Please state the business name and type of business:
Is the business food registered? Yes No
Please provide the approximate number of people per day served/catered for in the
previous calendar year:
Q3.e Residential establishment e.g. school, hotel, hospital, residential home
Average number of people accommodated on the premises per day during previous
calendar year.
Q3.f Holi
day accommodation e.g. holiday let, B&B, camp site, caravan site, holiday-village
Please detail all of the accommodation
on the premises
Number of
accommodation type
Max. number of guests
accommodated per day using the
accommodation type.
Example Caravan/ camping pitches
5
30
Holiday let
Caravan/Camping pitches
Caravans
B/B rooms
Bunk house
Q3.g Wat
er used for recreational purposes e.g. hot tub, sauna, swimming pool,
Please provide further details on type and maximum number of users per day:
Q3.h Others
If you have not completed any of the previous parts, please provide details as to what the premises
are used for:
Classification: NULBC PROTECT Personal
FORM PO1
Classification: NULBC PROTECT Personal
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Maximum number of people using the premises per day during the previous calendar year
Q4 Water Source
Please indicate, if known, the nature of the supply. If you have more than one type of water supply
identify which is primary (P) and which is secondary (S).
borehole dyke ditch lake pond reservoir well spring stream river
other - please specify
Is the source of the water located on land that you own? Yes
No
If no, please give the name and address of person who owns the land.
Name:
Address:
Please give the location of the supply e.g. OS grid reference or 600 meters south west halfway up the
hill or enclose a map.
Q5 Water Provision
Is your water supply shared by other properties / buildings?
Yes No (go to Q6)
If yes, could you provide a list of the other properties/ buildings concerned, including
any buildings that are unoccupied?
* Farmhouses with agricultural dwellings in the same family ownership, please list the dwelling’s
name and tick the right hand box.
Tick if
agricultural
dwelling.
Please continue in additional information if necessary
Classification: NULBC PROTECT Personal
FORM PO1
Classification: NULBC PROTECT Personal
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Q6 Water Treatment
Please indicate, if known, if the water is treated
No
Yes
End of questionnaire Please tick all that apply
Filtration UV filter with pre filter U/V filter without pre filter Chlorination
Iron removal pH correction Manganese removal Nitrate removal
other (please specify)
Is the treatment process located on your property?
Yes No Please specify the location of treatment process
Is your treatment system serviced routinely?
Yes
I have a contract with an external company. Please provide the name of the company
I service the equipment myself.
No
7 Please use this box as a con
tinuation from any section or to add additional information.
THANK YOU FOR TAKING THE TIME TO COMPLETE THE QUESTIONNAIRE
Any questions please email environmental_health@newcastle-staffs.gov.uk or call 01782
717717 and ask for Hallan Sambrooke.
By Post to Newcastle-under Lyme Borough Council, Castle House, Barracks Road,
Newcastle-under-Lyme, ST5 2LS.
Further information can be found on our website by clicking the following link
www.newcastle-staffs.gov.uk/privatewater
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FORM PO1: Classification: NULBC PROTECT Personal THE PRIVATE (Newcastle-Under-Lyme Borough Council)

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Completed 17 December 2020

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