DEPARTMENT OF PUBLIC HEALTH ENGINEERING

ANNEXURE A

APPLICATION FOR NON-AVAILABILITY OF WATER SUPPLY

(FOR COMMERCIAL CONNECTION)

Application Processing Location

Select office location to which application is to be submitted *

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** Application will be submitted to the respective Office Of PHE , based on the location selected above *

Applicant Details

Full Name *

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E-Mail Id *

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Mobile Number *

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District *

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Village/Town *

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Locality *

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Post Office *

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Police Station *

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Pincode *

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Commercial Establishment

Name of Commercial Establishment *

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Address of Commercial Establishment *

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Village/Town *

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Pincode *

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District *

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Sub Divisional Office for Application *

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Number of persons working in the premise *

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Water requirement per day demand *

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Any other information *

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Declaration

I hereby declare that all the particulars furnished in this application are correct to the best of my knowledge. I shall be held responsible for any incorrect information.

I Agree *