APPLICATION FOR CONNECTION/DISCONNECTION TO RECYCLED WATER …
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Doc Number: WW-FRM-419 Date Effective: 08/02/2021 This document is uncontrolled when printed. Document Owner: Water and Waste Version 1 – ECM 4728253 Page 1 of 2 ISAAC.QLD.GOV.AU P 1300 472 227 F 07 4941 8666 A PO Box 97 Moranbah QLD 4744 isaacregionalcouncil isaacregionalcouncil Isaacrcouncil ISAAC REGIONAL COUNCIL ABN 39 274 142 600 APPLICATION FOR CONNECTION/DISCONNECTION TO RECYCLED WATER NETWORK Isaac Regional Council is collecting personal information you supply on this form in accordance with the Information Privacy Act 2009. Your personal information will be used by Council officers who have been authorised to do so. The information will not be given to any other person or agency unless required by law or unless your permission is sought. Personal information will be handled in accordance with the Information Privacy Act 2009. APPLICANT DETAILS BUSINESS NAME ABN CONTACT PERSON POSTAL ADDRESS PHONE EMAIL SIGNATURE DATE PROPERTY DETAILS STREET ADDRESS RECYCLED WATER ALLOCATION REQUEST DETAILS PURPOSE OF USE OF WATER FROM NETWORK TOTAL VOLUME PER WEEK DAYS AND TIMES OF SUPPLY LOCATION OF CONNECTION POINT (PLEASE SUPPLY MAPPED LOCATION) IS IRRIGATION SYSTEM PRESSURE RELIANT OR TANK SUPPLY (IF PRESSURE RELIANT PLEASE SUPPLY PRESSURE REQUIRED AS SYSTEM MAY NOT HAVE THE CAPABILITY) ANY OTHER DETAILS
Transcript of APPLICATION FOR CONNECTION/DISCONNECTION TO RECYCLED WATER …
Doc Number: WW-FRM-419 Date Effective: 08/02/2021 This document is uncontrolled when printed.
Document Owner: Water and Waste Version 1 – ECM 4728253 Page 1 of 2
ISAAC.QLD.GOV.AU
P 1300 472 227 F 07 4941 8666 A PO Box 97 Moranbah QLD 4744
isaacregionalcouncil isaacregionalcouncil Isaacrcouncil
ISAAC REGIONAL COUNCIL ABN 39 274 142 600
APPLICATION FOR CONNECTION/DISCONNECTION TO RECYCLED WATER NETWORK
Isaac Regional Council is collecting personal information you supply on this form in accordance with the Information Privacy Act 2009. Your personal information will be used by Council officers who have been authorised to do so. The information will not be given to any other person or agency unless required by law or unless your permission is sought. Personal information will be handled in accordance with the Information Privacy Act 2009.
APPLICANT DETAILS
BUSINESS NAME
ABN
CONTACT PERSON
POSTAL ADDRESS
PHONE
SIGNATURE DATE
PROPERTY DETAILS
STREET ADDRESS
RECYCLED WATER ALLOCATION REQUEST DETAILS
PURPOSE OF USE OF WATER FROM NETWORK
TOTAL VOLUME PER WEEK
DAYS AND TIMES OF SUPPLY
LOCATION OF CONNECTION POINT (PLEASE SUPPLY MAPPED LOCATION)
IS IRRIGATION SYSTEM PRESSURE RELIANT OR TANK SUPPLY (IF PRESSURE RELIANT PLEASE SUPPLY PRESSURE REQUIRED AS SYSTEM MAY NOT HAVE THE CAPABILITY)
ANY OTHER DETAILS
Doc Number: WW-FRM-419 Date Effective: 08/02/2021 This document is uncontrolled when printed.
Document Owner: Water and Waste Version 1 – ECM 4728253 Page 2 of 2
ISAAC.QLD.GOV.AU
P 1300 472 227 F 07 4941 8666 A PO Box 97 Moranbah QLD 4744
isaacregionalcouncil isaacregionalcouncil Isaacrcouncil ISAAC REGIONAL COUNCIL ABN 39 274 142 600
APPLICATION FOR CONNECTION/DISCONNECTION TO RECYCLED WATER NETWORK
WATER SERVICE DETAILS
Size 50mm ☐ 100mm ☐ Other
☐ Additional Water Meters Size Number
☐ New Water Connection Service
☐ Disconnect Water Service
AUTHORISATION
REQUESTED BY Signature
DATE Print Name
DEPARTMENT USE ONLY
NEW METER DETAILS
Meter No. Size
Reading Installation Date
PROCESSED BY Signature
DATE Print Name
Once completed please send form and any attachment to:
[email protected] or Isaac Regional Council, PO Box 97, Moranbah QLD 4744
or deliver in person to your local Isaac Regional Council office
