Installation of Backflow Prevention Device

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					                                                                                                                            Scenic Rim Regional Council
                                                                                                                                     PO Box 25, Beaudesert 4285
                                                                                                                             Beaudesert Administration Centre
                                                                                                                            Ph: 07 5540 5111 Fax: 07 5540 5103
                                                                                                                                 Boonah Administration Centre
                                                                                                                            Ph: 07 5463 3000 Fax: 07 5463 2650

                                                                                                                                           mail@scenicrim.qld.gov.au
                                                                                                                                           www.scenicrim.qld.gov.au


ABN: 45 596 234 931                                   Installation of Backflow Prevention Device
    SECTION ONE – APPLICANT DETAILS
    Property Owners Name: ..........................................................................................................................
    Telephone Number: ...................................................Fax Number: ........................................................
    Address: ..................................................................................................................................................
    ........................................................................................................................Postcode: ........................

    SECTION TWO – DEVICE DETAILS (Tick the appropriate box)
    Reduced Pressure Zone                                           Registered Air Gap                                        Double Check Valve
    Pressure Type Vacuum Breaker                                                                Non-testable devices
    Make: .........................................................................Model:...................................................................
    Size:...........................................................................Serial Number: .....................................................
    Location of device: ..................................................................................................................................
    .................................................................................................................................................................

    SECTION THREE – SITE DETAILS
    Street Number: ..........................................................Unit Number: ........................................................
    Street Name:............................................................................................................................................
    Suburb: ......................................................................Postcode: .............................................................
    RP/SP: .......................................................................Lot Number:..........................................................

    SECTION FOUR – OWNERS TERMS OF ACCEPTANCE
    Conditions of approval for installation of Backflow Prevention Device.
     1. The owner must make sure the testable device is kept in working order and inspected for operational
         functioning every (12) months A non-testable device replaced device replaced/tested every five (5)
         years by a licensed backflow prevention device maintenance and testing contractor.
     2. The owner must ensure the licensed backflow prevention device maintenance and testing contractor
         provides a report of the inspection of test to Council within ten (10) days of the inspection or test.
     3. The owner shall pay to Council an annual licence fees as detailed in it schedule of general charges
         being for the annual registration of the device.
     4. Application must be made to Council’s Building and Plumbing section prior to removal of a Backflow
         Prevention Device.

    Failure to comply with conditions
      1. Council, may under the provisions of Section 1066 of the Local Government Act 1993, where the owner
          has failed to keep the device in working order and inspected for operational functioning, carry out any
          tests and inspections considered appropriate.
      2. Failure to submit the testing report to Council by the prescribed time may result in prosecution
          proceedings by Council for breach of the Standard Plumbing and Drainage Regulations 2003.

    As owner I confirm that I have read the terms of acceptance and accept them


    Owners Signature: .................................................                    Date: ...........................................................

           Installation of Backflow Prevention Device                                                                                           Page 1 of 1
           Last saved by christy.s – 24/09/2008

				
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Description: Installation of Backflow Prevention Device