Onsite Wastewater System

Application Form

This application is required under the Porirua City Council General Bylaw part 25 Wastewater, to ensure owner compliance under the Health Act 1956, Resource Management Act 1991 and Local Government Act 2002 to maintain health & safety and to safeguard the environment.

Please return the completed application, certificate of fitness and licence fee per onsite wastewater system to:

Porirua City Council

PO Box 50218

Porirua 5240

NB: Fees and charges for Onsite wastewater can be found on Porirua City Council’s website.

Please note that each onsite wastewater system requires a separate application form and fee.

Onsite Wastewater

Property Owner's & Authorised Person Form

The purpose of the checklist is to give guidance to authorised persons when carrying out an inspection of onsite wastewater systems. It is the objective of the inspection to determine that the system under inspection is performing in a manner that is not/unlikely negatively impacting on public health or the environment. Please complete a separate application for each onsite wastewater system and provide a site plan.

Property Owner Details / Application No:
Property Owner Name/s: / Date:
Property Address:
Postal Address:
Home Phone: / Work Phone:
Mobile Phone: / Email:
No. of occupants in household: / No. of bedrooms:
No. of WC/s: / No. of Gully Traps:

Location of System

Global Positioning System co-ordinates are:

And/or Are plotted on an attached map:Yes / No

Authorised Person

Name:
Company: / Contact Ph:
Knowledge/Experience/Qualifications regarding type of system being assessed:

Inspection Date

Next full system inspection date due:
(This information will be used for calculation of licence renewal date) / .…../……/……
Next de-sludging due (pump out): / …../……/……
Is there a supplier's maintenance contract in place? Yes / No
(If Yes, please submit a copy to Council)

Onsite Wastewater System Checklist

GWRC Consent

Has a Greater Wellington Regional Council Consent been granted? Yes / No
Does the daily wastewater discharge volume exceed1300 litres? Yes / No
  • Description of Treatment System

Effluent Treatment Type: (please tick appropriate box)

CATEGORY A
Primary & Secondary & Tertiary for black/grey water waste /  / CATEGORY B
Primary & Secondary for black/grey water waste / 
CATEGORY C
Primary for black/grey water waste /  / CATEGORY D
Holding tank / 
CATEGORY E
Composting toilet & separate treatment of grey water /  / Black = waste from toilets
Grey = waste from sinks, washing machines, etc. / 

Household Foul Water Drainage System Assessment: (please tick appropriate box)

Date of Installation / ………..… / Or date of estimated installation / ………..…
Length of Drain from house to treatment chamber: / < 10 metres /  / > 10 metres / 
Ground cover over foul water drain: / < 400mm /  / >400mm / 

Site clearances (provided on a site plan):

Separation Distance from: / Treatment Separation Distance (M) / Disposal Field Separation Distance (M)
Boundaries / …………………… (M) / …………………… (M)
Surface Water (streams, creeks etc) / …………………… (M) / …………………… (M)
Groundwater / …………………… (M) / …………………… (M)
Stands of Trees/Shrubs / …………………… (M) / …………………… (M)
Wells, water bores, below ground water tanks / …………………… (M) / …………………… (M)
Embankments/retaining walls / …………………… (M) / …………………… (M)
Buildings / …………………… (M) / …………………… (M)
Other (specify): / …………………… (M) / …………………… (M)

Evaluation Household Septic Chamber: (please tick appropriate box)

Size: / <500 Litres /  / <1000 Litres /  / >1000 Litres /  / >3000 Litres / 
Type: / Single Chamber /  / Dual Chamber /  / Multi Chamber /  / Other / 
Inflow Pipe: / Accessible /  / Non accessible / 
Outflow Pipe: / With outflow filter /  / Without outflow filter / 

Comments

  • Land Application for the disposal of septic effluent

Disposal system operates: (please tick appropriate box)

Above ground /  / Below ground /  / Natural gradient /  / Pressurised / 
Siphon /  / Pump/Sump with alarm and cut off for HWL and LWL /  / Spray /  / Irrigation / 
Other (Describe) /  / ……………………………………………………………….……
Type of disposal system: (please tick appropriate box)
Shallow/Trench system /  / Evapo transpiration seepage trench beds /  / Evapo transpiration beds /  / Earth mounds / 
Sub surface drip /  / Surface drip (trickle) to ground /  / Surface spray (pressurised) /  / Other / 
Distribution box (splitter box): (please tick appropriate box)
Without alternating control /  / Manual control /  / Automatic sequencing /  / Missing / 

Comments

Factors influencing the above: (please tick if applicable)
Ground water/surface water movement /  / Water table (seasonal/tidal movement) /  / Cut off drains / 
Open storm drainage /  / Fences to prevent unauthorised person /animal entry /  / Buffer zones distances to water courses/marine areas / 
Suitability of ground for percolation / Yes  / No 
Adequate sized effluent disposal field /  / Size of effluent reserve field / …m2
The depth of the seasonal water table:
Depth Measured /  / Depth Estimated / 
Winter / ….(M) / Summer / …..(M)
Vegetation Cover & type (describe):
……………………………………………………………………………………………………..………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
Direction of surface/sub surface water flow into ground aeration zone: (please tick appropriate box)
Up gradient of septic chamber /  / Down gradient of septic chamber /  / Flat gradient / 
Presence of ground cuts, embankments impacting on septic chamber Yes / No

Comments

ONSITE WASTEWATER MAINTENANCE CHECKLIST

Drain Inspection Evidence of: (please tick if applicable)
Surcharging from gully traps /  / Gully traps below ground level /  / Stormwater downpipe connected to gully traps / 

Comments

Actions required/taken:

Tank Inspection Evidence of: (please tick if applicable)
Tank subsidence /  / Tank structural damage /  / Ground subsidence /  / Odour emission / 
Ground water infiltration /  / Surface water entry /  / Fresh Air Inlet Missing / 

Comments

Actions required/taken:

Land Application Disposal of Septic Effluent Inspection Evidence of:
(please tick if applicable)
Surface water holding effluent waste /  / Sub surface water holding effluent waste (ground leaching) /  / Exposed or collapsed trenches/drain-age systems /  / Accessibility of inspection lids to drainage system: (rodding eyes) / 
Hydraulic overloading /  / Blocked disposal/
seepage fields /  / Odour /  / Evidence of surcharging / 
Evidence of cross connections /  / Evidence of surface water infiltration/
Seepage / 

Comments

Actions required/taken:

Inspection Undertaken by;

……………………………………………………………

Authorised Person - Name

…………………………………………………………………………………

SignatureDate

Schedule 3 – Certificate of Fitness

TO:Environmental Standards

Policy, Planning and Regulatory Services

PORIRUA CITY COUNCIL

1.This is to confirm that the Onsite wastewater system servicing for:

(Name of Property Owner)

ADDRESS:

Road/street number:
Road/street name:
Lot No: / DP:
Co-ordinates:

was inspected by me on the ______day of ______20____

2.I certify that:

(a)The onsite wastewater system has been assessed having regard to the checklist attached.

(b)The onsite wastewater system is not likely to create a nuisance within the meaning of Section 29 of the Health Act 1956, and / or interpretation section of Bylaw Part 25 Wastewater of the Porirua City Council General Bylaw 1991.

SIGNED:
(Authorised Person)
NAME:
(Authorised Person)
CONTACT DETAILS:
(Authorised Person)
DATE:

PCC #36074391June 2017