| Applicant's Name |
| Address |
| Date |
| I hereby apply for permission to construct a Sewage Disposal System at the location indicated below and submit the information listed below. |
| I fully understand that if permission is given it will be for carrying out construction work only, and that further approval before the installations can be put into use is required. |
| Location of site Building type |
| Average No. of users No. of Bedrooms |
| No. of Sewage Bowls Urinal Bidet |
| W/Basins |
| Yours faithfully |
| | |
| Signature | |
| I have inspected the site and report as follows: |
| | |
| ENVIRONMENTAL HEALTH OFFICER | |
| Date |