IWK Submission Form

FORM SSA / PDC / 1
SEWERAGE SERVICES ACT 1993 SEWERAGE SYSTEMS AND SEPTIC TANKS (PLANNING, DESIGN AND CONSTRUCTION) REGULATION 1996 (Regulation 3) APPLICATION FOR SEWERAGE PLANNING APPROVAL
Date: To: The Director General of Sewerage Services
I/We (the undersigned) IR. HASSAN BIN SULAIMAN hereby apply for sewerage Planning Approval to undertake the following sewerage works: INFRASTRUCTURE OF SEWERAGE TREATMENT PLANT (STP)
and submit the following particulars ( see reverse of form): 1) SEWERAGE LAYOUT PLAN (3 SET) 2) SEWERAGE ENGINEERING REPORTS (3 SET) ______________
Details of Land. Address of site or premises: PERMOHONAN PELAN SISTEM PEMBETUNGAN DI BAWAH AKTA 133 BAGI TUJUAN PENDIRIAN BANGUNAN SEKOLAH KEBANGSAAN PENDAS LAUT YANG MENGANDUNGI A) SEBUAH BANGUNAN SEKOLAH 2 TINGKAT, B) SEBUAH BANGUNAN TADIKA 1 TINGKAT, C) SEBUAH PONDOK PENGAWAL, C) SEBUAH RUMAH SAMPAH, DI ATAS LOT PTD 3396 MUKIM TANJUNG KUPANG, DAERAH JOHOR BAHRU, JOHOR DARUL TAKZIM Lot No. of land occupied by sewerage works: Area of land occupied by sewerage works: a) b) Sewerage Treatment Plant Network Pumping Station : 2.023 hectares.
: _________ hectares.
Detail Of Population Equivalent (PE) TYPE RESIDENTIAL COMMERCIAL INDUSTRIAL OTHER TOTAL DEVELOPMENT PE 50 PE 50 PE TOTAL PE REMARKS
SCHOOL
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IWK/DSS
Address and Lot Nos of any other land affected by the sewerage works:N/A ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
________________________________ Signature of Owner Name of Owner (in block letters): I/C No. : Address:
Telephone No: Fax No:
Declaration by Qualified Person I hereby certify that the details in the plans and engineering report are in accordance to the 'Guidelines for Developers',the MS 1228 Code of Practice for Design and Installation of Sewerage Systems and other regulatory agencies requirements.
________________________________ Signature of Qualified Person Name of Qualified Person (in block letters): IR. HASSAN BIN SULAIMAN I.C No.: 611015-01-5233 Address: OMNI PROJECT CONSULTANCY SDN BHD No. 4A, Jalan Pulai Perdana 12, Taman Sri Pulai Perdana, 81110 Skudai, Johor Bahru Telephone No.: 07-5202422 Fax No.: 07-5204542 Qualification and Registration particulars:
FOR OFFICIAL USE ONLY
Date received: ____________________________________ Date replied : _____________________________________

CheckedBy: ________________ Ref. No: _____________________

IWK/DSS
Particulars (on reverse of form) The following particulars are to be submitted with each application for Sewerage Planning Approval: 1) Layout Plan of the whole development. 2) Engineering Report (for development over 30 units). 3) (For developments of less than 30 units) a plan showing how each house is to be connected with any existing or proposed sewer or septic tank, the position and course of all surface water channels or drains, the names of streets adjoining the premises and the scale of the plan. A location plan. Details of land title, Lot No. and area of land. Consent letter from owners of other land affected by the proposed sewerage works or approval from the relevant authority as the case may be. In the case of reserved land, a letter of consent from the relevant authority in charge of the land.
4) 5) 6)
7)
IWK/DSS
DECLARATION FOR SEWERAGE WORKS PLANNING APPROVAL JOHOR BAHRU SSD Regional Office: ____________________________
Date: __________________
File No. Project Title
: : PERMOHONAN PELAN SISTEM PEMBETUNGAN DIBAWAH AKTA 133 BAGI CADANGAN PEMBANGUNAN DAN PELAN SUSUNATUR PERUMAHAN, SELUAS 171.64 EKAR DI BANDAR PENAWAR, MUKIM TANJUNG SURAT, DAERAH KOTA TINGGI, JOHOR DARUL TAKZIM : JURUKUR SEJATI : 6A, TINGKAT 1, JALAN A, OFF JALAN TUN ABDUL RAZAK,, 80000 JOHOR BAHRU, JOHOR DARUL TAKZIM
License Land Surveyor Address
Telephone/Fax Lot No/PT Mukim/Village/Town District State Land Title No Area of STPs /NPS Land Status of STP Developer Consultant Proposed Treatment System Development Type Population Equivalent (PE) Catchments
: 07-2238925/07-2242129 : : TANJUNG KUPANG : JOHOR BAHRU : JOHOR DARUL TAKZIM : PTD 3396 : ______________________________________________ : State Land / Alienated Land / Reserved Land : ISKANDAR INVESTMENT BERHAD : OMNI PROJECT CONSULTANCY SDN BHD : SEWERAGE TREATMENT PLANT : SCHOOL : 50 PE : N/A
Declaration by Qualified Person I hereby certify that all written information provided by me in this checklist is full, complete, true, and correct and are in accordance to the Guidelines for Developers and with the MS1228 Codes of Practice for Design and Installation of Sewerage Systems.
............................................................. (Signature) Date : Name: ..
IWK/DSS

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FORM SSA / PDC / 1

Telephone No: Fax No:

FOR OFFICIAL USE ONLY

Date received: Date replied : _

CheckedBy: Ref. No: _____

File No. Project Title

License Land Surveyor Address

............................................................. (Signature) Date : Name: ..

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