Application form for new connections, disconnections and additional units 1
Otama Rural
Water Supply Scheme
Application form for new connections, disconnections
and additional units.
29 Bowler Avenue, Gore 9710
PO Box 8, Gore 9740
Phone 03 209 0330
Email info@goredc.govt.nz
www.goredc.govt.nz
What is the purpose of this application?
New connection Transfer of existing restricted allocation
Disconnection Relocation of existing point of supply
New water meter Increase/decrease of existing restricted allocation
Upgrade of existing service line
Select the following if:
You are applying for a new restricted connection
You are transferring existing water allocations
If you are transferring existing water allocations
Total No. of Units/m
3
to be transferred:
No. of Units/m
3
from Tank # (as shown on the attached plan):
No. of Units/m
3
to Tank # (as shown on the attached plan):
If you are applying to increase/decrease your existing water allocation
No. of Units/m
3
to be increased Tank # (as shown on the attached plan):
No. of Units/m
3
to be decreased Tank # (as shown on the attached plan):
If you are applying for a disconnection
Note:
Disconnection
means the property will not attract water rates, however, disconnection fees apply and a
new connection fee may apply upon reconnection.
Are you disconnecting a metered connection? Yes No
Meter Serial No. 1. 2. 3.
Application form for new connections, disconnections and additional units 2
Conditions and Notes
Submitting an application for water supply services does not imply approval of the application.
Any approval granted is subject to the terms and conditions of the Gore District Council Water Bylaw.
It is the applicant’s responsibility to read and understaand the bylaw, which is available on our website
www.goredc.govt.nz, or phone 2090330
On-site storage equal to a minimum of two days supply shall be installed to properties with restricted
connection to the Councils water supplies.
The installation of water connections to points of supply shall be carried out by the Councils designated
contractor/water supply caretaker or designated representative.
The supply shall be for the exclusive use of the identified property and no supply pipe shall cross into or
supply any other peoperty.
The Council does not guarantee a continuous supply and reserves the right to restrict or impose
restrictions on the use of supply.
All fees and charges shall be paid prior to any works being carried out following assessment of this
application, please refer to the Councils fees and charges.
Note
A detailed site plan showing property boundaries, existing water services and the proposed works
must be attached to this application. The application will not be processed without a plan.
The preferred position of the connection, or the location of the connection to be removed/relocated,
together with marked distances/measurements to the nearest boundaries must be shown on the plan.
Applicant Declaration
I, the undersigned, hereby declare that the information given on this application is true and correct. I am authorised
to make this application in the name of the legal owner and in doing so, accept the conditions of supply outlined in
this application.
Name:
Signature:
Date:
Office Use
Plan attached: Yes No Date Received:
Application form for new connections, disconnections and additional units 3
Please send your completed form and relevant documents/plans to:
Email - sonell@goredc.govt.nz
Post - Gore District Council, P O Box 8, Gore, 9740
Deliver - Civic Administration Building, 29 Bowler Avenue, Gore.
click to sign
signature
click to edit
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