Questions marked with an asterisk (*) must be completed. If the space provided on the form is insufficient, attach a separate sheet.

Applicant and Owner Details

Provide details of the applicant and the owner of the land where the permit is being applied for.

Applicant*

The person who wants the permit.

First Name:

Surname:

 
 

Organisation (if applicable):

  
 

Postal Address:

  
 

Suburb/Locality:

 

Postcode:

Contact Details*

Daytime Phone:

  
 

Email:

  

Owner*

The person or organisation who owns the land.

Where the owner is different from the applicant, provide details about that person or organisation

Owner same as applicant

  
 

First Name:

Surname:

 
 

Organisation (if applicable):

  
 

Postal Address:

  
 

Suburb/Locality:

 

Postcode:

Contact Details

Daytime Phone:

  
 

Email:

  

 

 

Site Details

Address of the land to which the application applies. Complete the Street Address or the Formal Land Descriptions if no street address.

Street Address *

Street Address:

  
 

Suburb/Locality:

 

Postcode:

If property does not have a Street Address please provide the Lot No or Crown

Allotment No and Section No and Locality or Township Name.

Lot No:

Crown Allotment:

Section No:

 

Locality/Township:

  

 

 

 

 

Plumber and Drainer/Contractor Details

Provide details of the Plumber and Drainer/Contractor who will be responsible for installing the system

 

Plumber*

First Name:

Surname:

 
 

Organisation (if applicable):

  
 

Postal Address:

  
 

Suburb/Locality:

 

Postcode:

 

Daytime Phone:

  
 

Email:

  
 

Licence Number:

  

Drainer/Contractor*

Same as Plumber

  
 

First Name:

Surname:

 
 

Organisation (if applicable):

  
 

Postal Address:

  
 

Suburb/Locality:

 

Postcode:

 

Daytime Phone:

  
 

Email:

  
 

Licence Number:

  

 

Building Details

Type of building (house, office, factory, other) 

 

 Number of bedrooms (including studies) 

 

Number of people expected to use the system per day* 

 

 

 

 

Number of Connected Fixtures

Baths 

 

Sinks 

 

Showers 

 

Basins 

 

Toilets 

 

Laundry Troughs 

 

Garbage 

 

Dishwasher 

 

Spas 

 

Spa Capacity in litre 

 

Garbage disposal units 

 

Other (please specify) 

 

 

 

Water Supply

Rainwater Tank 

Yes 

 

No 

 

Mains Water Supply 

Yes 

 

No 

 

 

 

Fixture Rating  

  

Extra wastewater producing fixtures  

  

Full water Reduction  

  

Standard water fixtures 

 

 

 

System Details

Fixture Rating  

  

Extra wastewater producing fixtures  

  

Full water Reduction  

  

Standard water fixtures 

 

 

Onsite Wastewater System Details

System Type: (e.g. primary system, secondary system, grey water system)

 

 

 

   

Manufacturers Name

 

Model Name

 

Certificate of Conformity No.

 

 

 

 

 

 

 

 

 

Absorption Trenches 

*Length (m) *Width (m)   *Depth (d)

 
 

450mm-500mm

 

 

 

 

Irrigation System

 *Sub-surface (m2) *Surface (m2)

 
 

 

 

 

 

Other Methods of Effluent Disposal 

(Please enter the method by which the Blackwater from the septic tank will be discharged). 

 

*Method type     *Effluent lines width *Effluent lines length 

 
 
 

 

 

 

Grounds for Exemption

Please provide details of reason for exemption requested.

 
 
 
 

 

 

 

 

 

 

 

Applicant and Owner Declaration

I understand that once installed, my system cannot be used until a final inspection of the system has been carried out and a Certificate of Approval to Use the system has been issued.

I declare that all information contained in this application is, to the best of my knowledge, true and correct.

Applicant Signature: ________________________________________ Date: _________________

Print Name: ______________________________________________

 

Owner Signature: ___________________________________________ Date: _________________

 

Print Name: ___________________________________________________

 

 

 

Payment  

 

 

 

 

Fee Payable:

 

 

 

 

 

 

 

Applications and payments can be

lodged:

 

 

 

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In person

Present the completed and signed form to make payment (eftpos, cash, visa, master card, cheque or money order)

At one of our Customer Service Centres

 

Brimbank Community and Civic Centre

301 Hampshire Road, Sunshine

 

Keilor Community Hub

704B Old Calder Highway, Keilor

 

 

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By mail (cheque or money order only).

Send the completed and signed form with your cheque or money order payable to

‘Brimbank City Council’

Mail to Brimbank City Council,

PO Box 70, Sunshine Vic 3020

 

 

Privacy Statement

The personal information requested on this form is being collected by Council for the purpose of meeting its legal obligations under the Environment Protection Act 2017 and associated or related legislation. The information will be kept confidential and identifying information will not be disclosed to any person for any other purpose. You may access your own information by contacting Council’s Environmental Health Services on 9249 4000.