FORM WSIA/PDC/1

SEWERAGE SERVICES INDUSTRY ACT 2006

WATER SERVICES INDUSTRY (PLANNING, DESIGN AND CONSTRUCTION OF

SEWERAGE SYSTEM AND SEPTIC TANK) RULES 2013

APPLICATION FOR SEWERAGE PLANNING APPROVAL

Date :

To: Sewerage Certifying Agency

I/we MAJLIS AMANAH RAKYAT (MARA)

hereby apply for the approval of the sewerage planning to undertake the following sewerage works/
septic tank works* :

CADANGAN UBAHSUAI DAN NAIKTARAF BANGUNAN RUMAH KEDAI LIMA

TINGKAT KE SEBUAH HOTEL BAJET LIMA TINGKAT DI ATAS LOT PT 1875
HINGGA KE LOT PT 1880, JALAN DEWAN SULTAN SULAIMAN 1,
KUALA LUMPUR.

Details of land

1. Address/Lot no. of land occupied by sewerage works/septic tank works*:

2. Area of land occupied by sewerage works

(a) Sewage Treatment Plant acres

(b) Pumping Station acres

(Note:* delete where appropriate)

Details of Population Equivalent (PE)

TYPE TOTAL PE REMARKS

RESIDENTIAL
COMMERCIAL
INSTITUTIONAL 315 PE
INDUSTRIAL
OTHERS
TOTAL DEVELOPMENT PE 315 PE
 FORM WSIA/PDC/1

Declaration by Owner

I MAJLIS AMANAH RAKYAT (MARA) the owner of the land where the sewerage works / septic tank works * :
will be carried hereby agree for said works to be carried out on the land.

Signature of Owner

Name of Owner :
(in block letters)

I.C.No.: :

Address: : MAJLIS AMANAH RAKYAT (MARA)

BAHAGIAN BINAAN DAN SENGGARAAN
TINGKAT 11,
IBU PEJABAT MARA,
21 JALAN RAJA LAUT,
50609 KUALA LUMPUR

Telephone No. : 03-2613 2580

Fax No. : 03-2694 9661
E-mail :

Declaration by Developer

I hereby declare that the information given are complete, true and accurate and this project/development
shall be carried out in strict compliance with the Water Services Industry Act 2006 and its subsidiary
legislations. I accept full responsibility to ensure all relevant works shall be completed accordingly.

Signature of Developer

Name of Developer
(in block letters) : MAJLIS AMANAH RAKYAT (MARA)
I.C. No. : BAHAGIAN BINAAN DAN SENGGARAAN
Address : TINGKAT 11,
IBU PEJABAT MARA,
21 JALAN RAJA LAUT,
50609 KUALA LUMPUR
Telephone No. : 03-2613 2580
Fax No. : 03-2694 9661
E-mail :

(Note:* delete where appropriate)

FORM WSIA/PDC/1
Declaration by Competent Person

I hereby certify that details in this form and all documents attached are complete and accurate. I further
certify that the sewerage planning has been prepared in pursuant to the Water Services Industry
(Planning, Design And Construction Of Sewerage System And Septic Tanks) Rules 2013.

Signature of Competent Person

Name of Competent Person : IR. SHAHIDAN SADIMAN

(in block letters) :
I.C.No.: : 651016-10-5851
Address: NO. 15-2, JLN. AU1A/4B,
TAMAN KERAMAT PERMAI,
54200 KUALA LUMPUR
SELANGOR DARUL EHSAN.
:
Telephone No. : 03-4251 5880
Fax No.: : 03-4251 6880
E-mail : ssdesignconsult@yahoo.com

(Note:* delete where appropriate)

Fee details:

Type of payment : ** Bank Draft/Government Cheque

Issuing Bank : Maybank
Date :
Cheque no. :
Validity :

(Note:* delete where appropriate)

FOR OFFICIAL USE ONLY

Receipt No. : :
Reference No. : :