JADUAL KELIMA/FIFTH SCHEDULE[Subperaturan 22(1)/Subregulation 22(1)]

BORANG G/FORM GENAKMEN SUMBER AIR KEDAH 2008

KEDAH WATER RESOURCES ENACTMENT 2008PERATURAN-PERATURAN SUMBER AIR KEDAH (PENGABSTRAKAN AIR) 2015

KEDAH WATER RESOURCES (WATER ABSTRACTION) REGULATIONS 2015

PERMOHONAN PENGABSTRAKAN AIR PERMUKAAN / APPLICATION FOR SURFACE WATER ABSTRACTION

Lembaga Sumber Air Negeri Kedah Aras 1, Blok E, Wisma Darul Aman,05503, Alor Setar, KEDAH.Tel: 04-7744650Faks: 04-7744655 Website: http://lsan.kedah.gov.my

(Semua bahagian permohonan ini hendaklah diisi dan mudah dibaca /All sections of this application should be filled in and legible){Sila tanda ( √ ) pada petak yang berkenaan / tick ( √ ) whichever is appropriate}

1.0 Butir-butir Pemohon / Particulars of Applicant

Nama / Name: __________________________________________________________________ No. Kad Pengenalan / I/C No.: _____________________

Alamat / Address: __________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

No. Tel / Telephone No. : ____________________________________ No Fax/ Fax No.: _______________________________________

Alamat Emel / E-mail Address: _____________________________________ No Pendaftaran /Registered No.: ___________________________________(Sila lampirkan Sijil Pendaftaran Syarikat/ Please attach company registration certificate)

2.0 Tujuan Pengabstrakan / Purpose of Abstraction

Pertanian/ Agriculture Industri/ Industry Domestik/ Domestic Akuakultur/ Aquaculture Lain-lain/ Others

3.0 Butiran Kapasiti Pengambilan Air Permukaan / Details of Surface Water Capacity

Kadar Penggunaan / Rate Usage : ___________( m3/jam )/ (m3/hour), ___________( m3/ hari )/ (m3/day), ___________( m3/ tahun )/ (m3/year)

Alamat / Address: ______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

No Lot / Lot No: ________________________ Mukim/Subdistrict: __________________________ Daerah/District: ____________________________

Rujukan Peta / Reference Map: ____________________________ U/N, ___________________________T/E

(Sertakan bersama dengan peta kunci yang menunjukkan lokasi pengambilan air beserta dengan rujukan grid RSO / to be accompanied by key map showing the exact location of the intake point with the RSO grid references)

4.0 Kaedah Pengambilan Air Permukaan / Method of Taking Surface Water

Muka Sauk / Intake:

a) Tarikh siap / Complete Date: ___________________ Tahun / Year

b) Paras Air Minimum / Water Level Min: ___________________ m

c) Paras Air Maksimum / Water Level Max: ___________________m

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Untuk Kegunaan Pejabat Sahaja / For Office Use Only

Tarikh Diterima / Date Received

No. Resit / Receipt No.

No Rujukan Titik Pengambilan / Point Intake Ref. No:

No Rujukan Lembaga / Board Reference No:

Pam / Pump:

a) Purata Kadar Pam / Average Pumping Rate: __________________ ( m3/ hari )/ (m3/day)

b) Kemampuan Pam / Pump Ability: __________________( m3/jam )/ (m3/hour)

Lain – lain / Others (Sila nyatakan / Please specify) ________________________________________________________________________

5.0 Maklumat Syarikat Perunding / Details of Consultant Company

Nama syarikat / Name of Company: ________________________________________________________________________________________________

Alamat / Address: ______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

No. Pendaftaran Syarikat / Company Register No.: ______________________________________No. Tel / Tel. No :________________________________

(Sila lampirkan salinan sijil pendaftaran syarikat / Please attach a copy of the company registration certificate)

6.0 Butir-butir Pemilik Tanah / Particulars of Land Owner

Nama / Name: __________________________________________________________________ No. Kad Pengenalan / I/C No.: _____________________

Alamat / Address: __________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

No. Tel / Telephone No. : __________________________________ No Fax/ Fax No.: ____________________________________

Status Tanah / Status of land: __________________________ Kebenaran / Consent given: Ya / Yes Tidak / No

Aktiviti guna tanah / Land use activity (within 500m radius):____________________________________________________________________________

Berdekatan badan perairan / Nearest surface water body: _____________________________________________________________________________

Sila lampirkan surat kebenaran daripada pemilik tanah dan pelan susun atur yang menunjukkan lokasi perigi yang dicadangkan / Please attach consent letterfrom owner of property and layout plan to show the proposed well location)

Saya memperakui semua maklumat yang diberikan adalah benar dan tepat sepanjang pengetahuan saya / I certify that the information provided is true and correct to the best of my knowledge.

______________________________________ ________________________Tandatangan pemohon / Signature of applicant Tarikh / Date

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