"Section 68 Activity Application Form" - Town of West Wyalong, New South Wales, Australia

This New South Wales-specific "Section 68 Activity Application Form" is a document released by the Bland Shire Council.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Section 68 Activity Application Form" - Town of West Wyalong, New South Wales, Australia

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PO Box 21,
BLAND SHIRE COUNCIL
West Wyalong
SECTION 68 ACTIVITY
Ph: 6972 2266
Fax: 6972 2145
APPLICATION FORM
Email:
council@blandshire.nsw.gov.au
LOCAL GOVERNMENT ACT
Please attach all the plans and supporting information required to this form.
APPLICATION NUMBER –OFFICE
SECTION A
(to be completed in full)
USE ONLY
► GENERAL INFORMATION
S68
• GENERAL INFORMATION
APPLICANT'S DETAILS
DA/CC
Title (Mr, Mrs, Ms, Miss, Dr, Etc): _________
Full Name/Company Name: _____________
TYPE OF APPROVAL YOU
____________________________________
REQUIRE
Postal Address: _______________________
____________________________________
 Roads Act Approvals
(Section B)
Daytime Contact Details:
 Sewerage work
Phone: _______________________
(Section C)
Mobile: _______________________
Email: ______________________________
 Install and operate an on-site sewage
Fax:
________________________
management system
(Section D)
Signature: __________________________
__________________________
 Discharge trade waste into Council's
sewer
(Section E)
WHAT PROPERTY IS THE SUBJECT OF
 Install a solid fuel heater
THIS APPLICATION?
(Section F)
Street Address: ______________________
 Theatrical, musical or other
___________________________________
entertainment for the public on
community land
Locality: ____________________________
(Section G)
Lot, Section, DP/SP: __________________
 Construct a temporary enclosure on
___________________________________
community land for the purpose of
entertainment
ACTIVITY DESCRIPTION
(Section G)
Briefly describe everything you want Council
to approve:
 Other: ________________________
_____________________________________
_____________________________________
1
PO Box 21,
BLAND SHIRE COUNCIL
West Wyalong
SECTION 68 ACTIVITY
Ph: 6972 2266
Fax: 6972 2145
APPLICATION FORM
Email:
council@blandshire.nsw.gov.au
LOCAL GOVERNMENT ACT
Please attach all the plans and supporting information required to this form.
APPLICATION NUMBER –OFFICE
SECTION A
(to be completed in full)
USE ONLY
► GENERAL INFORMATION
S68
• GENERAL INFORMATION
APPLICANT'S DETAILS
DA/CC
Title (Mr, Mrs, Ms, Miss, Dr, Etc): _________
Full Name/Company Name: _____________
TYPE OF APPROVAL YOU
____________________________________
REQUIRE
Postal Address: _______________________
____________________________________
 Roads Act Approvals
(Section B)
Daytime Contact Details:
 Sewerage work
Phone: _______________________
(Section C)
Mobile: _______________________
Email: ______________________________
 Install and operate an on-site sewage
Fax:
________________________
management system
(Section D)
Signature: __________________________
__________________________
 Discharge trade waste into Council's
sewer
(Section E)
WHAT PROPERTY IS THE SUBJECT OF
 Install a solid fuel heater
THIS APPLICATION?
(Section F)
Street Address: ______________________
 Theatrical, musical or other
___________________________________
entertainment for the public on
community land
Locality: ____________________________
(Section G)
Lot, Section, DP/SP: __________________
 Construct a temporary enclosure on
___________________________________
community land for the purpose of
entertainment
ACTIVITY DESCRIPTION
(Section G)
Briefly describe everything you want Council
to approve:
 Other: ________________________
_____________________________________
_____________________________________
1
SECTION C
SECTION A (CONTINUED)
SEWERAGE WORK
GENERAL INFORMATION
PROPERTY OWNER'S CONSENT
Details of installer (if different from Applicant)
(Note: All owners must sign this consent)
As the owner/s of the above property, I/we
Name:
consent to the lodgement of this Application. I/we
Address:
permit officers of Council to enter the land to carry
Phone:
out inspections as required for the assessment of
Mobile:
this application and will provide access where
Email:
required.
Fax:
License Number/Accreditation No: ________
Name
Signature
Date
SECTION D
INSTALL & OPERATE OSSMS
Name
Signature
(Septic System)
Date
Company Name
INSTALLATION/OPERATION OF AN ON-
Name
SITE SEWAGE MANAGEMENT SYSTEM
Signature
What do you wish to do?
Date
 Install a new system
 Alter an existing system
 Operate an existing system
SECTION B
► USE OF THE ROAD RESERVE
What type of system do you wish to install?
 Aerated waste water treatment system
(AWTS)
What do you propose to do?
 Septic tank - on-site disposal (absorption
• DEVELOPMENT DETAILS
trench)
 Construct road works including drainage
 Septic tank - on-site disposal
 Construct a footpath
(transpiration beds)
 Construct a driveway
 Composting toilet
 Control traffic
 Other system (please specify):
 Pumping of water into a road
_______________________________
 Connect to another road
 Creation of work zones for buildings
Details of installer (if different from Applicant)
 Erect hoardings
Name:
 Operate a footway restaurant
Address:
 Hold a road event
Phone:
Mobile:
Note: A detailed report/letter must be submitted detailing
the intended activities that are proposed to be carried out.
Email:
Fax:
License Number/Accreditation No: ________
2
SECTION E
SECTION G
► COMMUNITY LAND
TRADE WASTE
• CONSTRUCTION DETAILS
TRADE WASTE
COMMUNITY LAND – ENTERTAINMENT &
TYPES OF WASTE TO BE DISPOSED OF:
ERECTION OF TEMPORARY STRUCTURE
Specific waste to be disposed of:
Description of the activity, component, process,
_________________________________
design or temporary structure:
____________________________________
DETAILS OF MANUFACTURER
____________________________________
Manufacturer (brand name):
Date: ______________________________
__________________________________
Proposed Hours: _____________________
Model Number: _____________________
NSW Health Accreditation Number:
Community Land:
__________________________________
__________________________
Note: A copy of a certificate of accreditation issued by the
Tank capacity: ______________________
Building Regulations Advisory Committee (within the
meaning of the Building Act 1993), if it is so accredited, or if it
is not, documentary evidence of any test procedures, results,
performances or appraisals relevant to the proposed
SECTION F
accreditation that have been obtained from a recognised
appraisal body.
►SOLID FUEL HEATER
►CONSTRUCTION DETAILS
SECTION H
SECTION C (CONTINUED)
INSTALLATION OF DOMESTIC SOLID
► OTHER
FUEL HEATING APPLIANCE
►CONSTRUCTION DETAILS
Details of installer (if different from applicant)
:
SECTION C (CONTINUED)
_______________________________________________
►CONSTRUCTION DETAILS
Name:
_______________________________________________
Address:
_______________________________________________
_______________________________________________
Phone:
_______________________________________________
Mobile:
Email:
Fax:
►ADDITIONAL INFORMATION
Details of appliance: _______________
License Number/Accreditation No:
Make:___________________________
PRIVACY AND PERSONAL
Model: __________________________
INFORMATION PROTECTION ACT 1998
Australian Standard Compliance Details:
(Section 10)
_______________________________________
The information you have provided with this
application is considered 'personal information' for
Note: Please attach plans detailing the location of
the
purposes
of
the
Privacy
and
Personal
installation within the premises and the location of fuel
Information Protection Act (PPIA) 1998, and is being
storage facilities.
collected as to enable an efficient and accurate
assessment of your application. The intended
recipients of the information are officers within
Council assessing the application, and any other
OFFICE USE ONLY
agent of Council. The information required by this
application is required by law, and failure to provide
Fee Type
Fee $
Job No.
the information requested will result in Council being
Sec 68 – B(Storm/Sewer) _________
4410-1506-0002
unable to process your application. You may make
Sec 68 – C(Septic Install) __________
application to access and correct the information
4410-1506-0004
you have provided by contacting Bland Shire
Sec 68 – C(Operate Septic)__________
4410-1506-0005
Council.
Sec 68 – D(Comm. Land) __________
4410-1506-0007
PLANS AND SUPPORTING
Sec 68 – E(Public Rd)
__________
4410-1506-0008
INFORMATION
Sec 68 – F(Other)
__________
4410-1506-0009
Please attach ALL of the plans and supporting
Inspection/FOC
__________
4410-1408-0000
information that is required for your application. Be
advised that Council cannot be held responsible for
Photocopy
__________
4410-1803-0000
any delays in processing arising out of inadequacies
in the material submitted in support of this
ap-
Total Fee
__________
Int. ___
plication.
Receipt No. ___________
Date. ___________
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