Schedule 5
(related To Sub-rule (1) Of Rule 12)

Schedule-5
(Related to Sub-rule (1) of Rule 12)

Application for the license to utilize the sources
Shree Chairperson,
District Water Resources Committee
This application has been submitted to get the license for utilizing the
drinking water sources, mentioning the following details-
1. Name and Address of a person or body corporate:-………………..……
2. Objectives:-………………………………
3. Name of the source intending to utilize:-…………….…………
4. Source situated, zone:-………………………. District:-………………..
Village Development Committee/Municipality:-…………………Ward
No.:-………….
5. Quantity of water to be utilized:-…………………..……
6. Estimated cost for the utilization of the sources:-……………….
7. Basis to the expenditure of utilization of water:-…………….
8. The number consumers to be benefited from the utilization of sources
and scope:-……………
9. Other details:-……………..
10. Documents to be submitted with the application:-
a) Reports on economic, technical and environmental aspects of
utilization of sources.
b) Map of the place where the source has been utilized.
c) One copy of the constitution of the organization if the utilizing
organization has been a body corporate.
The details mentioned above are true, if proved false, I shall be liable for
the consequences.
Applicants:-
Signature:-
Name:-
Address:-
Date:-
Seal of the VDC/Municipality