Fillable NEW CONNECTION AS-BUILTS SUBMISSION FORM (Selwyn District Council New Zealand)

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NEW CONNECTION AS-BUILTS SUBMISSION FORM (Selwyn District Council New Zealand)

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NEW CONNECTION AS-BUILTS SUBMISSION FORM
PO Box 90, Rolleston 7643
Tel. (03) 347-2800
Email: water.services@selwyn.govt.nz
GENERAL
As-built must be submitted by e-mail to to the Council's Water Services accompanied with pictures and plan no later
than two working days after completion of the work.
CONTACT DETAILS
Company Name Contact phone
Contact Name Contact E-mail
LOCATION OF WORK
X_ Coordinate (NZT 2000 projection only) Y_ Coordinate (NZT 2000 projection only)
Distance from main to property boundary (m) Distance from main to water meter and toby (m)
Distance from main to valve/ hydrant/ sump/
manhole (m) Distance from lateral to R/L property boundary (m)
Please attach a plan of the as-built
Refer to our Engineering Code of Practice for more
information
Plan check-list:
Plans have offsets to pipes, manholes and laterals distances from legal boundaries
Laterals for individual lost have the pipe layout shown and a written measurement shown
from the boundary line
NEW ASSETS DETAILS
New pipe: New Supply point: Backflow preventor: Other:
Type Type (meter, restricted) Type Type
Diameter (mm) Diameter (mm) Model/Make Model/make
Model/Make Model/Make Certification # Manufacturer
Serial #/ Maric size Serial #/ Maric size Serial # Diameter (mm)
Length (cm) Length (cm) Manufacturer Length
Depth (cm) Depth (cm)
Inside / outside
boundary Depth
Diameter (mm) Reading
Manufacturer Manufacturer
Material
Please feedback on any issue encountered with infrastructure in place
DECLARATION
I declare that all information given in this form is correct
I have attached plans and pictures of assets installed
Installed by: Certified by:
Date:
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NEW CONNECTION AS-BUILTS SUBMISSION FORM (Selwyn District Council New Zealand)

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Completed 29 July 2020

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