Application for connection to water and/or sewerage services.pdf

ROSCOMMON COUNTY COUNCIL
Application for Licence to open road and/or to connect to a water supply or sewerage services
PART 1
DETAILS OF APPLICATION
1. Name of Applicant: ___________________________________ Phone No: _____________________
2. Current Postal Address of Applicant: ____________________________________________________
3. Purpose for which licence is required: (Tick in appropriate box)
a) Connection to Water Supply €1,600 per connection
b) First Agricultural Connection €1,600 per connection
c) Additional Agricultural Connection €600 per connection
d) Sewerage Connection €1,600 per connection
e) Connection to Surface Water Drainage €1,600 per connection
f) Connection to Group Water Scheme €600 per connection
g) Road Opening Licence for any purpose other
than connection to water supply or sewer
€600 per road opening
h) Road Opening Licence for connection to Water
Supply/Sewerage (This refers to Planning
Permission applied for on/after 10 th March 2004)
€600 per road opening
(N.B. Proof of Payment of development levy must be submitted with this application)
State purpose: ___________________________________________________________________
4. Location of connection/opening (Townland or Street): ___________________________________
(N.B. Site map must be submitted showing exact location of development and proposed connection.)
5. Diameter of connection pipe: _______________________________________________________
6. Description of premises to which connection is to be made: _______________________________
7. If more than one dwelling is involved, state number of dwellings: __________________________
(In the case of connections to housing estates or apartment blocks, the licence fee must cover the total
number of proposed dwellings for which planning permission/approval was granted).
8. State whether premises is new or existing: _____________________________________________
9. If Planning Permission was granted within the past five years, state:
(a) Date Granted ______________________ (b) Planning Ref. No. ____________________
10. Name and Address of Contractor who will open the road _________________________________
____________________________________________________________________ Phone No: ___________________
11. Applicants are responsible for materials and employment of Contractor to make the connection.
12. Contractors must satisfy Roscommon County Council insurance requirements.
13. Advance notification of connection must be given to Roscommon County Council.
14. The relevant County Council Waterworks Caretaker/Sewerage Caretaker must supervise the connection

Declaration of Contractor
I confirm that I have been retained by the above named applicant to carry out the road opening for
the work proposed. (Note: It will be necessary to furnish proof of public liability of €6.348m to
Roscommon County Council before the licence can be issued)
Signed: ________________________________________
Date: ____________________
Please note Contractor must stamp form as well as sign it.
PART 2
Contractor’s Stamp:
UNDERTAKING AND PAYMENT OF FEES
15. I agree to carry out the works in accordance with Roscommon County Council’s requirements, which are
set out in the Standard Conditions.
16. I agree to pay appropriate water charges, which may be levied from time to time by Roscommon County
Council.
17. In consideration of Roscommon County Council granting me a Licence for the purpose as set out at 3
above, I enclose herewith the sum of €_______________ being the appropriate licence fee. (see 3 above)
Signed: _________________________________
Date: ____________________
PART 3 – FOR OFFICAL USE ONLY
FINANCE SECTION:
Road Opening Licence Fee of €_______ received
and Official Receipt No. ___________ issued.
Initials: _____________ Date: ____________
WATER SERVICES SECTION:
Certificate of Insurance checked.
Yes & in Order
Initials: __________ Date: _________
RECOMMENDATION OF ENGINEER
Decision - Grant/Refuse
Recommendation on Application - Grant/Refuse
Signed: ________________________________
Senior Executive Engineer
Date: ___________________
Signed: _________________________
Senior Engineer
Date: ___________________