Fillable WATER, WASTEWATER AND STORMWATER NETWORK ACCESS REQUEST (Queenstown Lakes District Council New Zealand)

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WATER, WASTEWATER AND STORMWATER NETWORK ACCESS REQUEST (Queenstown Lakes District Council New Zealand)

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TO BE COMPLETED BY THE DIRECTOR OF THE COMPANY THAT WILL BE ACCESSING THE WATER,
WASTEWATER AND/OR STORMWATER NETWORK, OR ANOTHER PERSON AUTHORISED BY THE COMPANY.
Please complete and return this form to: networkauthorisation@qldc.govt.nz
Phone: (03) 441 0499
Website: www.qldc.govt.nz
1. YOUR DETAILS
First name:
Company:
Last name:
Business address
Street number:
Street name:
Suburb: Postcode:
Work phone: Mobile:
Email:
Yes No
Are you requesting annual access? This is permitted for non-entry access only.
If you have answered yes, proceed to 3. Declaration below and complete and sign.
2. SITE AND JOB DETAILS
If there are multiple locations please attach a separate list.
Site address:
Please describe the
job and include the
asset ID. This can
be found from the
QLDC GIS map.
Proposed access date:
AUTHORISATION
I declare that I am authorised to sign on behalf of the company.
Name: Signature:
Job title: Date:
WATER, WASTEWATER
AND STORMWATER
NETWORK ACCESS REQUEST
3. DECLARATION
These are mandatory requirements. If the work does not require entry into a manhole, please tick the boxes on the
left. If the job involves conned space entry, please tick the boxes on the right to conrm each statement.
Non-entry Entry
I have read, understand and will comply with the terms and conditions (see below)
The company follows health and safety procedures that comply with the requirements of the Health and
Safety at Work Act 2015
All staff undertaking the work have the required safety training, equipment and can assess hazards and
implement controls
All staff undertaking the work have obtained unit standards 25510 and 3058 in gas detection by an
organisation accredited by NZQA*
All staff undertaking the work have obtained unit standards 17599 and 19207 in conned space entry by
an organisation accredited by NZQA*
All staff undertaking the work have obtained unit standard 18426 in demonstrating knowledge of hazards
associated with conned spaces by an organisation accredited by NZQA*
All staff undertaking the work have obtained unit standards 6401 and 6402 in rst aid by an organisation
accredited by NZQA such as St John First Aid Level 1 (required to be refreshed every two years)
I have attached the specic Job Safety Analysis with the appropriate controls to manage hazards on site
I have attached evidence of the conned space permitting system for all staff entering the manhole
I have attached the methodology for managing wastewater ows (if applicable)
I have attached the methodology for the specic works
Name: Signature:
Job title: Date:
Company director or authorised person
* it is industry good practice for these unit standards to be refreshed every two years
4. FOR OFFICE USE ONLY
APPROVED BY
Name: Signature:
Job title:Network authorisation number: Job title:Proposed access date:
Comments
/ additional
requirements:
Job title: Date:
5. TERMS AND CONDITIONS
• The work must be carried out in accordance with QLDC Codes of Practice and Standard Operating Procedures,
without damage to the water, wastewater, or stormwater networks
• The person carrying out the work must complete a Job Safety Analysis with appropriate controls to manage trafc,
pedestrians, biological substances, gases (such as methane and hydrogen sulphide), animals, illegal substances
and any other hazards relevant to the work. The work must be carried out in accordance with the controls in the
Job Safety Analysis
• All other necessary approvals, permits and notications, for example approvals from the electricity network services
providers, WorkSafe, or trafc management approval from the New Zealand Transport Agency and/or Council, must
be obtained before work begins
• If any QLDC assets are damaged in carrying out the work, those on site must notify QLDC immediately on
Queenstown 03 441 0499 or Wanaka 03 443 0024. All costs associated with the repair will be recovered by QLDC
• If asset faults such as a blocked public pipe or a cracked manhole lid are discovered, QLDC must be notied
immediately
• A copy of this approval must be kept on site at all times
• All staff must carry photo identication
• All staff have undertaken the required testing, inoculations, and immunisations (Appendix 3)
• Nothing in this approval, including the conditions of approval, limits QLDC’s rights and powers under the QLDC
Water Supply Bylaw 2015 or any Act (in particular the Local Government Act 2002) and/or under the general law in
relation to the protection of its networks, and/or liability by the company or any other person for damage, misuse or
interference to its networks
• QLDC’s approval is limited to authorising investigations in its wastewater, stormwater, and/or water networks, as
specied in this application. QLDC has no liability to the company accessing the network, or any other person in
relation to the works carried out or any consequences of those works.
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WATER, WASTEWATER AND STORMWATER NETWORK ACCESS REQUEST (Queenstown Lakes District Council New Zealand)

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Completed 20 January 2021

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