FORM RA1

Refer Chapter IV (A) Pāra 1

KERALA WATER AUTHORITY 13100

APPLICATION FOR WATER PERMANENT/CASUAL/NEW CONNECTION
SEWER

1. Name : ________________________________________________

2. Address : ____ . __________________________________________

3. HouseNo. : ________________________________________________

4. Details of Licenced
Plumber for Internai
Pipe laying

a)Name : ________________________________________________

b) Address : ________________________________________________

c) Licence No. : ________________________________________________

5. ConsumerCategory : DOMESTIC/NON DOMESTIC/

INDUSTRIAL/PANCHAYAT/
MUNICIPALITV/CORPORATION

6. Division :

Sub-Division :

7. Water Supply Consumer No. :

8. Other Particulars :

l hereby agree the rules and conditions of Authority for connection.

Date.......................... Signature

APPROVAL OF LOCAL BODY

Above application may be considered

Subject to ________________________________________________________________

Date Signature/Seal
of Local Body

INTIMATION TO THE APPLICANT

Kindly pay estimate fee of Rs ..................................................................................................

to the Cashier and submit this application to the undersigned along with receipt.

Date................... Assistant Executive Engineer

For Office Use Only

1. Estimiate fee: Rs.......................Receipt No...................... dt..............................
2. Estimiated Deposit Rs.......................Receipt No........................... dt..............................
3. Appliocation Fee Rs.......................Receipt No............................ dt..............................
4. Special Deposit Rs.......................Receipt No............................ dt..............................
5. Final Payment Rs.......................Receipt No............................ dt..............................

Asst. Executive Engineer

 KERALA WATER AUTHORITY
Form No. RA 1 a
Application for Water Connection
(Not Transferable)

Note: l. Please do not leave anv column unattended.

2. Please use CAPITAL letters for filling this page

Division

Sub Division

Section

Area

1 Name of Applicant
:
2 Address for communication :

3 Address of premises to which connection is required

1. Building No :

2. House Name :

3. Street/Lane :

4. Posi Office :

5. Pin Code :

6. Survey No. :

7. Near House No :

8. Near KWA Consumer No. :

9. TelephoneNo. (if any) :

4 Category of connection required

l. Domestic Single dwelling unit

Multi dwelling units : No. of units :

Govt. School : No. of students :

Govt. Hospital : No. of beds :

Others (specify

2. Non-domestic Multipurpose

Office : No. of Staff :

Hall, Mandapam : Capacity :
Hostel : No. of occupants :
Shop : No.of staff :
Restaurant : No.of seats :
Hostel & Lodging : No. of beds :
Private School : No. of Students :
Colleges : No. of Students :
Hospital Clinical : No. of beds :
P.C. Station : No of toilet :
Temple :
Church :
Mosque
Park/Garden
3. Industrial Specify the Industry
4. Special Casual Construction
Exhibition/Fairs etc
5. Others (specify)
5 Quantity of water required per day

l. Expected quantity required / day

2. If alternate source available, give details

6
Building Details
l. Building Permit No. & date :
2.Plinth area
7 Present stage of cunstruction
Notstarted Partiallycompleted Completed Occupied
1. Ifpartially completed, present stage :
2. Present source ofwater, ifany :
3. No. ofoccupants (present/excepted) :
8 Details of plumbing Works
1. Inside installation done or not
2. Approval No. & datē if done
3. Sizeofconnectionrequired
4. No. of taps
5. No. offlushing cisterns
6. No. ofothertapingpoints
7. Totaloutlets
9 Waterconnection is to a sump or not
If yes, give the details,
1. Size(LxBxH)/Capacity :
2. Material ofconstruction :
3. Water tightness tēst conducted or not :
4. Details of pumping system :
10 Details of previous connections at site, if any :
11 Whether the applicant is an existing consumer of Kerala Water
Authority

If yes, give the details,

1. Consumer Number/s :
2. Section :
3. Subdivision :
12
List of enclosures
1 Chvnership Certificate fromtheLocal body (obtained within3 months of datē ofapplication)
2 Plumbing plan - 3 copies attach additional copies ifroad/Berm cutting is necessary)
3 Necessary postage stamps for the acknowledgment card, road cut card, provisional approval carcL
13 Declaration of the applicant

1. I hereby undertake that all the details given above āre true to the best of my knowledge and belief.
2. IherebyauthorizeM/s................................................... to execute the Plumbing work.
3. I have read/understood the relevant clauses of the Kerala Water Authority (Water Supply)
Regulation, 1991 and hereby agree to abide by the same.

Dated Signature of the Applicant

14 Details ofPIumbēr
1. Name :
2. Nameoffirm :
3. Address :
:
4. LicenseNo :
15 Decla ration of the Plumber

1. Iherebydeclarethatlhavepersonallyinspected1hepremisestowhich1hewaterconnection
is applied for and the details given above āre correct to the best of my knowledge.
2. I hereby declare to undertake and complete the work as per the rules of the K.W. A.
3. All the inside installation will be/has been done as per the water supply rules.
4. I have personally conducted and satisfied the water tightness tēst of the sump.

(Seal) Dated Signature of the Plumber

For Office Use
1.
. Sub Division Office
RegisterNo. :

1. Datē of receipt of application :

2. Verificationcertificateof application :

Dated Signature of D/man

3. FonvardedtotheAssistantEngineer,..................................... Sectionon.......................
for site inspection, feasibility report and remarks.

Dated Signature of Assistant Executive Engineer

II
Section Office

1. Fonvarded to W.W.L/Overseer, .............................................. on.......................

Dated Signature of Assistant Engjneer

 2. Report of W.W.I./Overseer

Dated Signature of W.W.I./Overseer

3. Feasibility report and recommendations of the Assistant Engineer

Dated Signature of Assistant Engineer

4.
Details of amount to be remitted

1 Deposit amount Rs.

2 Connection Fee Rs.
3 Street main extension charges Rs.
4 Inside Fee Rs.
5 Extension Fee Rs.
6 Centage charges Rs.
7 Others (specify) Rs.
8 Fines (specify) Rs.
Total Amount Rs.

Submitted to the Assistant Executive Engineer on .......................................

Dated Signature of Assistant Engineer

III Sub Division Office

l Therequest for the sanction of ......................................... cutting is sent to
the............................................................................................. on...............................
Dated Signature of Assistant Executive Engineer
2. Date of receipt of the sanction for road cutting at the sub division is on ................

Dated Signature of D/man

 3. Provisional Approval of the connection
1 kindly pay an amount of Rs......................................... (Rs...................................................................
.............................................only) to the Sub Divisiontowards the watersupply connection.
2 You āre requested to producē a sound water meter with tēst certificate.
3 You āre requested to execute the vvater supply agreement with the undersigned on any
working day after the remittance of the above amount.
4 If you fail to comply with the above within three months, this approval / sanction for
vvater connection shall be considered as cancelled.

Dated Signature of Assistant Executive Engineer

4 Intimationtotheapplicant

Intimation to the applicant sent on.............................................

Dated Signature of D/man
4 Collection of amount at the sub division and allotment of consumer No.
1 Receipt Nos. and datē :
2 Amount :
3 Consumer No.allotted :
4 Categoryofconnection :
5 PIC assigned, KL/month :
6 PIC amount/month :
7 Work order No. :

Dated Signature of Cashier/J.S. of Sub Division

5 Issue of Work Order
Work order issued and transmitted to the AssistantEngineer on .......................................

Dated Signature of Assistant Executive Engineer

IV Section Office
1 Dateofreceiptofcompletionreport :
2 PriorityNo. :
3 Datē of connection :
Dated Signature of Assistant Engineer
1 RemarksofW.W.I./Overseer

Connection given on..........................................and the provisional invoice and meter reading

card issued to the consumer.
Dated Signature of W.W.I./Overseer
2 Remarks of the Assistant Engineer

Dated Signature of Assistant Executive Engineer