SEPTIC TANK PLAN REQUEST FORM

							                2009-2010
    DATE PAID:....................
    RECEIPT NO: ..................
                                                                                         ABN: 42 686 389 537
    AMOUNT PAID: ...............                                                     P O Box 151 Kyneton Vic 3444
    CASHIER'S INTITIALS: .....                                              Telephone (03) 5422 0333 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 $32.00
                                                              Permits issued before 1995       $64.00
                                                      [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 registered owner, written permission is required
                                                                                                     from the registered owner prior to any information 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)


        Applicant’s Signature:                                                   .............................................................................................................................
        Date:                                                                    .....................................................
        REGISTERED OWNER’S DECLARATION:                                                               (if applicant is not registered owner)

        I, __________________________ , being the registered owner of the above property give my
                       Registered Owner’s Name (please print)
        permission for information requested on this form to be supplied to the above applicant.

        Registered 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.



        Property Address: .................................................................................................................................................................................................

                                                          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:                               ____________________________________________________



        2009 - Application Form - Request for Septic Plans - 1 July 2009 .doc                                                           1/7/2009 to 30/6/2010                                               6 July 2009