Schedule-4
(Related to rule 11)

License to survey the source
License No.:- …….
Shree…,
Sir/Madam,
This license has been issued to you to survey the source of drinking water
according to the following terms.
1. Name and Address of license: – ………
2. Objectives of survey: – …………
3. Area/Region to operate the survey:-……..
4. Time to start (initiate) the survey:-…………..
5. Duration to complete the surveying:-…….
6. Time period for prevailing the license:-………
7. Conditions to be fulfilled by the licensee:-
a)
b)
c)
d)
Certificate issuing officer:-
Signature:-
Name:-
Designation:
Office:-
Date:-