SEPTIC TANK PLAN REQUEST FORM20104114350 by lindayy

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									AMOUNT PAID: $ ...................................

DATE PAID:............................................

RECEIPT NO: .........................................
                                                                                               ABN: 42 686 389 537
                                                                                    P O Box 151, Kyneton Vic 3444
CASHIER INITIALS: ...............................
                                                                           Telephone (03) 5429 9661 Facsimile (03) 5422 3623


                                                         SEPTIC TANK PLAN REQUEST FORM
                                                         A NON-REFUNDABLE FEE IS REQUIRED TO BE PAID FOR ALL SEARCHES
                                                                    Permits issued in 1995 and later $28.50
                                                                    Permits issued before 1995       $57.00
                                                          [The Fee for this application includes GST under Division 81 of the GST Act]

APPLICANT’S DETAILS:                                                          (Please Note:       If applicant is other than the present owner, written permission from the
                                                                                                 present owner is required prior to any information regarding this request
                                                                                                 being supplied to the applicant).

Applicant’s Name:                                                              ..................................................................................................................
Applicant’s Postal Address:                                                    ..................................................................................................................
Being:                                                                         Owner / Plumber / Builder / Other .............................................
Applicant’s Contact Phone No: ..................................................................................................................
Reason for Request:                                                            ..................................................................................................................
PROPERTY DETAILS:
Street No. & Name:                                                             ..................................................................................................................
Town:                                                                          ..................................................................................................................
Lot No:                                                                        .....................LP/Subdivision No:............................................ ...........
Owner when house was built:                                                    ..................................................................................................................
or List of Previous Owners:                                                    ..................................................................................................................
                (Previous owner’s names are
                   listed on Copy of Title)
                                                                               ..................................................................................................................

PRESENT PROPERTY OWNER’S DETAILS:
Present Owner’s Name:                                                          ..................................................................................................................
Present Owner’s Signature:                                                     ..................................................................................................................
Date:                                                                          ................................................


Information if available that will assist:
Building Approval Numbers for Dwelling and Additions
Approval No.       Owner at time         Application Date                                                                                        Approval Date
...........................                               .................................     .....................................          ...............................
...........................                               .................................     .....................................          ...............................
PRIVACY NOTIFICATION:                                      The personal information requested on this form is being collected by Council for the processing and
                                                           administration of your request. Council and its Contractors will use the personal information for that primary
                                                           purpose or directly related purposes and may be disclosed as required by law. The applicant may apply to the
                                                           Council for access to and/or amendment of the information.


                                                               CREDIT CARD PAYMENT (BY MAIL) – Septic Tank Plan Request
    Please charge my credit card for the amount of $_________________                                                             Bankcard             Mastercard                Visa Card

    Credit Card No:                                                                                                                                Expiry Date: _______/_______
    Name:                                   ___________________________________________________ (please print)
    Signature:                              _____________________________________________________


T:\Health\Forms\2006\Septic Tank\REQUEST FOR SEPTIC TANK PLAN .doc                                                                                                                   26/07/2006

								
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