Form NOTIFICATION OF SELF CERTIFICATION OF A PROPOSED INSTALLATION

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					                                                                                                                                 Form S2a-05/05


                                               NOTIFICATION OF SELF-CERTIFICATION OF A
                                               PROPOSED INSTALLATION OF A SEPTIC TANK
                                                OUTSIDE OF A BUILDING CONTROL AREA
                                        Public Health (General Sanitation, Mosquito Prevention, Rat Exclusion and Prevention) Regulations


This form and the layout are to be completed and submitted to the local environmental health office at least 7 days prior to
commencement of the works. If the Environmental Health Officer elects to carry out inspection and testing , the self-certifying
plumber will be notified within two (2) days of receipt of this notification. An incomplete or illegible submission may negate this
notification.

1.          LOCATION OF SEPTIC TANK INSTALLATION
Address _______________________________________________________________________________________________

Premises Description ____________________________________________________________________________________
                                (e.g. 3BR house, 2BR flat/unit, 10 person office, 25 person factory, 65 seat restaurant & 5 staff, etc.)

2.          SUMMARY OF PROPOSED SEPTIC TANK SYSTEM
Type of Septic Tank ____________________________________________________ Capacity ___________________ litres
                                       (conventional septic tank system only)

Type of Effluent Disposal System ________________________________ Cell Type ___________________ Length _______
                                    (e.g. soil absorption, evapotranspiration bed)                  (e.g. Reln, Atlantis, etc)

Width & Depth of Trench/Bed _______________________________ Soil Type ______________________ LTAR __________
                                                                                                                                             2
                                                                                                (clay, loam, sand, etc)                   L/m /day

3.          OWNER

Name of Owner _________________________________________________________________________________________

Address of Owner _______________________________________________________________________________________

4.          SELF-CERTIFYING PLUMBER
Name of self-certifying plumber _____________________________________________________________________________

Address of self-certifying plumber ___________________________________________________________________________

Telephone ________________________ Fax ___________________________ Mobile ______________________________

                                            Plumber and                                         Indemnity Insurance
Building
                                            Drainer Lic. No.                                    for residential dwelling?
                                                                                                                                  YES : NO
Practitioner No.


Signature   __________________________________________                          Date   ______ /______ /______
                                    Certifying Plumber

NOTE: In some areas a Beneficial Use for groundwater may be declared under the Water Act. The
reference source to check for declarations is the Natural Resources Division of the NT Department of
Planning and Infrastructure. (Telephone 8999 3632 - Land and Water Advisory Service).
Darwin Urban (DHCS)             Darwin Rural (DHCS)               East Arnhem (DHCS)                  Katherine (DHCS)
Ground Floor, Casuarina Plaza   2nd Floor, Casuarina Plaza        Community Health Building           Ground Floor, Government Centre
PO Box 40596                    PO Box 40596                      Endeavour Square                    PMB 73
CASUARINA NT 0811               CASUARINA NT 0811                 PO Box 421                          KATHERINE NT 0851
Telephone: (08) 8922 7377       Telephone: (08) 8922 7481         NHULUNBUY NT 0881                   Telephone: (08) 8973 4811
Facsimile: (08) 8922 7036                   (08) 8922 7483        Telephone: (08) 8987 0440                      (08) 8973 8767
                                Facsimile: (08) 8922 7334                    (08) 8987 0441           Facsimile: (08) 8973 8592
                                                                  Facsimile: (08) 8987 0444

Barkly (DHCS)                   Alice Springs (DHCS)              Tiwi Health Services (DHCS)         Katherine West Health Board
Health Development Building     60-62 Hartley St                  AANT Building,                      Unit 10, Riverbank Office Village
Cnr Schmidt & Windley Sts       PO Box 721                        81 Smith St, Darwin                 Cnr First St & O’Shea Tce
PO Box 346                      ALICE SPRINGS NT 0871             PO Box 40596                        PO Box 147
TENNANT CREEK NT 0861           Telephone: (08) 8955 6122         CASUARINA NT 0811                   KATHERINE NT 0852
Telephone: (08) 8962 4302       Facsimile: (08) 8952 5927         Telephone: 0401 116 030             Telephone: (08) 8971 9300
Facsimile: (08) 8962 4420                                         Facsimile: (08) 8985 8003           Facsimile: (08) 8972 1233
Address of Conventional Septic Tank System ____________________________________________________________

Certifying Plumber & Drainer __________________________________________________________________________

Note: The Certifying Plumber & Drainer is required to detail the following on this page:
Site Layout: showing shape of allotment and boundaries, location building(s) and structures including bores, watercourses,
sheds, pools etc, location, size and details of the septic tank, effluent disposal field, the direction of the natural fall of the land.

Setback Distances from septic tank and effluent disposal area to site features including buildings, allotment boundaries,
swimming pool, bore, watercourse, cutting, water tank, other septic tanks & effluent disposal areas.
                                                                                                                                Form S2b-05/05


                                    CERTIFICATION OF INSTALLATION OF A SEPTIC TANK
                                         OUTSIDE OF A BUILDING CONTROL AREA
                                    Public Health (General Sanitation, Mosquito Prevention, Rat Exclusion and Prevention) Regulations




This form is to be completed and submitted to the local environmental health office within 14 days of completion of installation of a
septic tank system. Documentation to accompany the form is described on the second page. Incomplete or illegible documentation
may delay acceptance of this certification.

1.        LOCATION OF SEPTIC TANK INSTALLATION
Address _______________________________________________________________________________________________

Premises Description ____________________________________________________________________________________
                                (e.g. 3BR house, 2BR flat/unit, 10 person office, 25 person factory, 65 seat restaurant & 5 staff, etc)


2.        SUMMARY OF PROPOSED SEPTIC TANK SYSTEM
Type of Septic Tank ____________________________________________________ Capacity ___________________ litres
                                       (conventional septic tank system only)

Type of Effluent Disposal System ________________________________ Cell Type ___________________ Length _______
                                    (e.g. soil absorption, evapotranspiration bed)                 (e.g. Reln, Atlantis, etc)

Width & Depth of Trench/Bed _______________________________ Soil Type ______________________ LTAR __________
                                                                                                                                            2
                                                                                               (clay, loam, sand, etc)                   L/m /day

3.        SELF-CERTIFYING PLUMBER
Name of self-certifying plumber _____________________________________________________________________________

Address of self-certifying plumber ___________________________________________________________________________

Telephone ________________________ Fax ___________________________ Mobile ______________________________

                                              Plumber and                                      Indemnity Insurance
Building
                                              Drainer Lic. No.                                 for residential dwelling?
                                                                                                                                 YES : NO
Practitioner No.



          CERTIFICATION
         I hereby certify that the above described works have been carried out in accordance with
         the requirements of the Northern Territory Code of Practice for Small On-site Sewage and
         Sullage Treatment Systems and the Disposal or Reuse of Sewage Effluent. I have also attached
all the necessary information required by Section 4 of this certification form.

        Signature ______________________________________                                                Date ____ /____ /____
                                           CERTIFYING PLUMBER

Darwin Urban (DHCS)             Darwin Rural (DHCS)              East Arnhem (DHCS)                  Katherine (DHCS)
Ground Floor, Casuarina Plaza   2nd Floor, Casuarina Plaza       Community Health Building           Ground Floor, Government Centre
PO Box 40596                    PO Box 40596                     Endeavour Square                    PMB 73
CASUARINA NT 0811               CASUARINA NT 0811                PO Box 421                          KATHERINE NT 0851
Telephone: (08) 8922 7377       Telephone: (08) 8922 7481        NHULUNBUY NT 0881                   Telephone: (08) 8973 4811
Facsimile: (08) 8922 7036                   (08) 8922 7483       Telephone: (08) 8987 0440                      (08) 8973 8767
                                Facsimile: (08) 8922 7334                   (08) 8987 0441           Facsimile: (08) 8973 8592
                                                                 Facsimile: (08) 8987 0444

Barkly (DHCS)                   Alice Springs (DHCS)             Tiwi Health Services (DHCS)         Katherine West Health Board
Health Development Building     60-62 Hartley St                 AANT Building,                      Unit 10, Riverbank Office Village
Cnr Schmidt & Windley Sts       PO Box 721                       81 Smith St, Darwin                 Cnr First St & O’Shea Tce
PO Box 346                      ALICE SPRINGS NT 0871            PO Box 40596                        PO Box 147
TENNANT CREEK NT 0861           Telephone: (08) 8955 6122        CASUARINA NT 0811                   KATHERINE NT 0852
Telephone: (08) 8962 4302       Facsimile: (08) 8952 5927        Telephone: 0401 116 030             Telephone: (08) 8971 9300
Facsimile: (08) 8962 4420                                        Facsimile: (08) 8989 8054           Facsimile: (08) 8972 1233
ATTACHMENTS AND INFORMATION REQUIRED FOR CERTIFICATION
(Tick the appropriate boxes for all the information supplied as attachments with this Certification)

Septic Tank                         Completed Certification Form
                                    One (1) copy of site layout plans (scale 1:500) showing shape of allotment and
                                    boundaries, location of building(s) and structures including bores, watercourses, sheds,
                                    pools etc, location, size and details of the septic tank, effluent disposal field, the direction of
                                    the natural fall of the land, setback distances, north point.
                                    One (1) copy of floor plans (scale 1:100) showing the house/building the use of individual
                                    rooms, all fixtures fittings, drains, I.O.'s, traps, junctions and floor level.
                                    Soil Type Information - Obtained by either soil classification or percolation tests.


Aerated Wastewater Treatment System

                                    All of the information required for a septic tank, i.e. compliance with type approval conditions,
                                    application fee, site & floor plans. Soil classification required if sub-surface disposal
                                    proposed.
                                    Details of the system including capacity, alarms, pumps,
                                    Type of effluent disposal system including type of irrigation (spray, dripper, sub-strata, sub-
                                    surface etc)
                                    Location & size of irrigation area and any proposed holding tanks, perimeter fencing,
                                    warning signs, etc.
                                    Specification of periodic maintenance requirements and estimated order of cost.


Composting toilets, chemical toilets, incinerating toilets & pit toilets


                                    All of the information required for a septic tank (ie. compliance with type approval conditions,
                                    application fee, site & floor plans). Soil classification is required if sub-surface disposal of
                                    effluent is proposed.
                                    Details of the system including capacity, and method of humus disposal for composting
                                    toilets.




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