5-71-T8

Application for an On-Site Wastewater Work approval

Pursuant to the South Australian Public Health (Wastewater) Regulations 2013, all on-site wastewater systems and alterations to on-site wastewater systems are subject to a wastewater works approval. Refer to the South Australian Department for Health and Wellbeing ON-SITE WASTEWATER SYSTEMS CODE (the Code) for further information to assist in the completion of this application form.

Each application must include complete information below, a detailed sanitary plumbing and drainage lay-out (refer to Section 8 of the Code), and a site and soil report (refer to Section 3.6.1 of the Code).

New Installation / Dwelling Total: $427*

Wastewater is disposed onsite

Eg. Sub-surface, Aerobic

Fee covers:

Application Fee
Two site inspections

*Complex and large applications may attract charge for additional site inspection(s).

FAILURE TO PROVIDE THE CORRECT INFORMATION WILL RESULT IN APPROVAL DELAYS

1. Applicant / Owner Details

Enquiries regarding this application will be directed to the applicant.

Applicant Full Name *

Phone *

Email

Applicant Address *

Street address *

City *

State *

Postcode *

If the applicant is not the owner, please also fill in the details below.

Owner Name

Owner Phone

Owner Email

Owner Address

Street address

City

State

Postcode

2. Location of Installation

Installation Adress

Street addressStreet address line 2

City

State

Postcode

Lot No.If Applicable

SectionIf Applicable

CT No.If Applicable

3. Premises Details

Premises description *

DwellingUnitsCommercial Other

If you selected 'Other' Please specify

Occupancy (residential premises)Number of persons

Occupancy (Non-Residential Premisies) Refer to APPENDIX E of the Code to decide on a suitable premises category to calcualate the capacity of the septic tank and the effluent disposal requirements.

Premises Category

P1

P2

Water Supply to premises *

Reticulated mains water supplied to premisesRoof catchment / storage or carted supplyOther

If you selected 'other' please specify

Non-Standard Fixtures

Food waste disposal unitSpa Bath (specify litres below)

Litre Capacity

4. Proposed type of Wastewater Works

What is the proposed type of watewater works?

New SystemAlteration / addition to an existing system

For an alteration / addition to the system or a design utilising more than one of the options below, please provide a brief description of works here or attach a covering letter to the application.Please ensure that the submitted plans show the existing pipework and fittings (as known) and the intended additions, making a clear visual distinction between the two

Tank Capacity

Make *

Model

Please ensure that all nominated system and components are on the Department for Health and Wellbeing Approved Products List: Wastewater products | SA Health

5. Effluent Disposal Method

This section should match the engineers recommendations in SIte and Soil Report.

Land Application of Effluent

SUBSURFACE DISPOSAL

Required contact area for subsurface disposal In square metres

Plastic Tunnel

Perforated Pipe

LengthMetres

Width Metres

Depth Millimetres

SUBSURFACE IRRIGATION DISPOSAL

Irrigation area requiredIn square metres

SURFACE IRRIGATION DISPOSAL

Irrigation area required (cannot be over lawn)In square metres

AS / NZ 1547 LAND APPLICATION DESIGN

Type

Basal Area

LengthMetres

WidthMetres

DepthMillimetres

OTHER

TEMPORARY ON-SITE CONTAINMENT FOR TANKER REMOVAL

Holding tank capacity Litres

OTHER METHOD - Please provide full details with attachments as appropriate

Please specify 'other' method

6. Land Capability Assesment

This section is relevant for applications intending land application for effluent

Within 50cm of a well, bore, or dam used or likely to be used for human or domestic purposes *

YesNo

Within 50m of a watercourse as identified on a 1:50 000 SA Government topographic map and used or likely to be used for human or domestic purposes *

YesNo

Above shallow underground water supplies used for human or domestic purposes *

YesNo

Within 100m of the mean high water mark along coastal foreshore areas *

YesNo

Within 50m of a water source used for agriculture, aquaculture or stock purposes *

YesNo

In an area likely to be subject to flooding or inundation in a 1:10 year recurrent event *

YesNo

SOIL REPORT: For applcations involving the land application of effluent, please provide a site and soil suitability report from a Wastewater Engineer if applicable

DLR / DIR or EPR nominated by the wastewater engineer

Upload Engineers Report *

Browse

7. Trade Waste Discharge

New ConnectionAlteration to a system with an existing trade waste connection

Provide details of the proposed activity and processes which produce wastewater

Provide details of pre-treatment system including its size and capabilityEg grease arrestor, pH correction, solid setting

Provide details of proposed cross connection and backflow prevention devices, where required

Details of wastewater discharge

GravityPumped

Peak flow rate (L) per second

Please attach additional information where required

Upload Plumbing Report / Other information

Browse

If Applicable

8. Declaration and signature of owner and applicant

The application must be signed by both the owner and applicant.

I / We hereby declare that the information provided in this application, attachments and accompanying plans are true and correct.

It is acknowledged that:

Pursuant to Regulation 11 of the South Australian Public Health (Wastewater) Regulations, the plumbing contractor(s) must provide a Certificate of Compliance to the relevant authorities following installation of an on-site wastewater system or components.
All work on the wastewater system must be carried out by persons licensed pursuant to the Plumbers, Gas Fitters and Electricians Act 1995.
Penalties apply for the provision of false or misleading information or failure to install and maintain the system in accordance with approval conditions.

It is the responsibility of the applicant to ensure that the wastewater works are installed in accordance with the approved plan and relevant conditions.

Owner's Signature *

Draw signature|Type signatureClear

Date of Signature *

Applicant's SIgnature *

Draw signature|Type signatureClear

Date of Signature *

I declare that all the information I have supplied is true and correct. I acknowledge that personal information provided may be used by the City of Port Lincoln for the purpose of Council business, as specified in Council's Privacy Policy.

*

Captcha *