AF OSSA Page 1 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
INTRODUCTION
The objective of this form is to collate the required site and soil information that will support QLDC with
evaluating the risks associated with installing any proposed Onsite Wastewater Disposal systems on a
new subdivision or greenfield site.
This form can be used in conjunction with AF OSW which is designed to cover both the site assessment
as well as the system design review.
REFERENCES
The design standard for waste water treatment and effluent disposal systems is AS/NZS 1547:2012. All
references within this form relate to this standard.
RISK BASED APPROACH
QLDC has adopted a risk based approach which involves evaluating key factors relating to the site and
soil features to ensure that any risk to environment or public health is fully mitigated. The key potential
risks that QLDC will consider include, but are not limited to, the following:
High risks
Pathogen risks
Moderate risk
Odours
Loss of amenity service due to technology failure, power outage
High capital and/or operating costs
Minor risks
Slope instability on the steeper sites
Noise
Risk to cultural values
Nutrients (nitrogen and phosphorus) and emerging contaminants
HIGH RISK APPLICATIONS
Throughout this application form there are a number of information fields that are highlighted in red.
These relate to key risk factors that the system designer must consider during their design process. If
these risks are present then an explanation of what design mitigations have been taken is required.
For systems that breach the requirements of Section 3, you will be required to raise an application with
the Otago Regional Council for a Resource Consent. Once the ORC Resource Consent has been granted
it can be referenced as part of the QLDC Building Consent Application.
QLDC reserves the right to engage expert peer review of applications that are either very high risk, or
system designs which appear to have inadequate design mitigations in place. The cost of this will be on-
charged to the applicant as part of their building consent fees.
AF OSSA Page 2 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
APPLICATION FORM CONTENTS
Introduction ................................................................................................................................................ 1
Application Form Contents ......................................................................................................................... 2
1 Site Description ................................................................................................................................... 2
2 Site Assessor ....................................................................................................................................... 3
3 ORC Resource Consent Requirements: ............................................................................................... 3
4 Site Assessment Details ...................................................................................................................... 4
5 Soil Investigation ................................................................................................................................. 5
6 Soil Category ....................................................................................................................................... 6
7 Attachments Checklist ........................................................................................................................ 7
8 Applicant Statement: .......................................................................................................................... 8
1 SITE DESCRIPTION
Property Owner:
Location Address:
Legal Description (e.g.
Lot3 DP1234) :
List any existing
consents related to
waste disposal on the
site:
General description of
development and
describe all sources of
wastewater:
AF OSSA Page 3 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
2 SITE ASSESSOR
Company
Contact Name
Email
Phone
Qualifications/Technical
Experience
3 ORC RESOURCE CONSENT REQUIREMENTS:
Please complete below checklist to confirm whether an Otago Regional Council (ORC) resource consent
will be required to discharge domestic waste water in the Queenstown Lakes District:
If any of these apply then you will need to make an ORC resource consent application for domestic
wastewater discharges to land with a maximum volume of 14,000 litres. The application form for this is
Form 6A
.
Once the ORC consent has been granted please enter the reference number below and provide a copy
of the approved ORC consent.
ORC Resource Consent Number:
Yes No System Requirement
Daily discharge volume exceeds 2,000 litres per day
Discharge will occur in a groundwater protection zone or in the Lake Hayes catchment
Discharge will occur within 50 metres of a surface water body
Discharge will occur within 50 metres of an existing bore/well used to supply water for
domestic needs or drinking water for livestock
There will be a direct discharge into a drain, water race or groundwater
Discharge may runoff onto another persons’ property
AF OSSA Page 4 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
4 SITE ASSESSMENT DETAILS
For the areas where the treatment plant and land application system and reserve area are to be
located, please provide the following information:
Land use description:
Topography:
Slope angle:
Vegetation cover:
Are there areas of potential ponding?
Are there risks associated with
drainage patterns and overland flow
paths?
Does site have Flood potential?
(show with return period on site
plan)
Yes
No
If Yes, please provide information below on what design
considerations have been adopted to mitigate this risk (e.g.
elevated tanks, sealed lids etc.)
Is the system within 100m distance
to nearest open water bodies,
emphemeral streams and wetland?
Yes
No
If Yes, please provide information below on what design
considerations have been adopted to mitigate this risk.
Is the system within 50m distance to
stormwater drains and stormwater
soakage areas?
Yes
No
If Yes, please provide information below on what design
considerations have been adopted to mitigate this risk.
AF OSSA Page 5 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
Are Water bores within 50m?
(reference ORC Maps)
Yes
No
If Yes then an ORC resource consent is required
Are there are other key site features
that may affect the system design?
Slope stability assessment- For land
slopes greater than 15
o
(25%)
summarize any areas unsuitable for
waste water irrigation.
What is the depth to the highest
potential ground water level:
Su
mmer:
Winter:
Information
Source:
Is there potential for waste water to
short circuit through permeable soils
to surface and / or
ground water?
Yes
No
If Yes, please provide information below on what design
considerations have been adopted to mitigate this risk.
5 SOIL INVESTIGATION
For the areas where the land application system and reserve area are to be located, provide the
following information
Has a Site Specific Field investigation been
completed? Is Report attached?
Yes
No
Note: Report shall include a plan showing test pit or
bore location, and a detailed soils report in
accordance with Table B2 and Figure B1 or and
equivalent format and detail.
Photos of the profiles and soils shall be included
including photos of soil ribbon tests (Section E4.1)
Field investigation date:
AF OSSA Page 6 of 8
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Onsite Wastewater Disposal Site & Soils
Assessment Form
Number of test pits or bores:
If fill material was encountered during the
soil investigation, describe the fill material
and explain how this will impact on the waste
water land application system design and
performance?
Has the soil permeability beneath the
proposed land application field been tested?
Yes
No
If Yes please provide details of test method and
results (e.g. Percolation test method (refer to B6
for applicability):
6 SOIL CATEGORY
Based on the site investigation report please confirm the soil category that is present for the land
application system.
Select
One
Soil Category
(Table 5.1)
Soil Texture (Appendix E
)
Drainage
Characteristic
Risk limits for
Groundwater Setback
1 Gravel and sands Rapid
5m
2 Sandy loams Free 5m
3 Loams Good 1.5m
4 Clay loams Moderate 1.5m
5 Light clays Moderate to slow 0.6m
6 Medium to heavy clays Slow 0.6m
AF OSSA Page 7 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
Is the groundwater
level (refer section 4)
within the above risk
limits for the site?
Yes
No
If Yes, please provide information below on what system design
considerations have been adopted to mitigate the risk to groundwater. For
example:
Secondary treatment
Tertiary UV treatment
Modified trench or bed details for category 1 soils to ensure even
distribution
Note: The soil category and groundwater level will determine the required loading rate for any land
application system.
7 ATTACHMENTS CHECKLIST
Select
One
Required Documents
Copy of any existing QLDC or ORC consents
Copy of QLDC Site & Soils Assessment (if previously completed)
Copy of slope stability geotechnical report (if required)
Copy of flood hazard assessment (if required)
Site Specific Field Investigation Report.
Ensure it covers information requirements covered in sections 5 &6
To scale site plan. The following must be included on the plan:
Buildings
Boundaries
Tr
eatment system components
Reserve disposal area
Retaining Walls
Embankments
Cutoff drains / diversion bunds
Water bodies
Stormwater drains, discharge points or soakage facilities
Flood risk areas
Other wastewater treatment units and discharge systems
AF OSSA Page 8 of 8
Last Updated: 24/05/2018
Revision 2
Onsite Wastewater Disposal Site & Soils
Assessment Form
Water bores
Direction of ground water flow
Existing and proposed trees and shrubs
North arrow
8 APPLICANT STATEMENT:
I believe to the best of my knowledge that the information provided in this application is true and
complete. I have the necessary experience and qualifications to design the above proposed waste
water treatment system in accordance with
the requirements of AS/NZS 1547:2012:
Name:
Si
gnature:
D
ate:
Pl
ease scan the completed document to PDF and upload along with supporting information to the QLDC
Sharefile portal:
http://www.qldc.govt.nz/index.php/planning/resource-consents/apply-online/
click to sign
signature
click to edit
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