Republic of the Philippines

Municipality of Molave
OFFICE OF THE MUNICIPAL HEALTH OFFICER

APPLICATION FOR DRINKING WATER SITE CLEARANCE

NAME OF APPLICANT (Surname, Given Name, M.I):
ARDEN O. YUTEEKIONG / AQUANIA WATER REFILLING STATION

ADDRESS (No., Street, City/Municipality, Province):

MORGAN ST., MOLAVE, ZAMBO. SUR

LOCATION OF WATER SOURCE:

BRGY. MAKUGUIHON, MOLAVE, ZAMBO. SUR
SOURCE OF WATER SUPPLY:
( ) Ground Water
( ) Well
____ Dog
____ Bored ____ Driven ____ Drilled Others please specify _______________
Diamter of Pipe ___ mm
( ) Spring
Location:
___ Downhill
___ Below Overhanging Rock
___ Level Ground
___ Scattered on a High Elevation
___ Inside a Cavern
___ Mountain/Hill Slope
___ Others Please Specify ___________________
( ) Surface Water
____ Pond ____ Lake ____Stream
Rainwater Impounding Reservoir _________
Others please Specify

MOLAVE WATER SYSTEM

PURPOSE OF WATER SUPPLY SYSTEM:

( ) Domestic/Residential

( ) Commercial

( ) Institutional

( ) Others Please Specify

TYPE OF WATER SUPPLY

( ) Level I - Point Source

( ) Level II - Communal Faucet System or Stand Posts

( ) Level III - Waterworks System or Individual House Connection

SCOPE OF WORK:
( ) Drill

( ) Construct

( ) Repair

( ) Extend

( ) Others ( Please Specify ) ___________

AREA TO BE SERVED BY THE WATER SUPPLY SYSTEM:

NO. OF POPULATION TO BE SERVED

WATER:

MOLAVE, ZAMBO.SUR

SITE CONTACT PERSON:

ADDRESS:

TELEPHONE NO. :
MORGAN ST., MOLAVE, ZAMBO.SUR

SKETCH OF SITE (Use the back page or addiional sheet if necessary):

(Indicate important landmarks and possible sources of contamination)

Note: For waterworks, Submit Water Permit from NWRB

OFFICER

SITE CLEARANCE
DATE:
13-May-15
TELEPHONE NO. :

_______________

hanging Rock
a High Elevation

( ) Industrial

em or Stand Posts

) ___________

LATION TO BE SERVED BY DRINKING

Signature of Applicant

Republic of the Philippines

Municipality of Molave
OFFICE OF THE MUNICIPAL MAYOR

DRINKING WATER SITE CLEARANCE

Based on the attached accomplished sanitary survey report, this drinking water site
clearance is hereby issued to

YUTEEKIONG, ARDEN ONG

(Name of Applicant)

of

MORGAN ST., MALOLOY-ON, MOLAVE, ZAMBO. SUR

(No., Street, Municipality/City, Province)

to

CONNECT (TAP)
Scope of Work (Construct/drill/others specify)

MOLAVE WATER SYSTEM ( MWS )

Source of Water Supply (ground water supply/ surface water supply (specify)

located at

BRGY. MAKUGUIHON, MOLAVE, ZAMBO. SUR

(No., Street, Municipality/City, Province)

Recommending Approval:

DR. PRISCO S. PABATAO JR.

Municipal Health Officer
Approved by:

IRENEO Q. GLEPA
Municipal Mayor

DSWC No:
Date Issued:
OR. :
Dated Issued:

Note: This clearance will automatically expire if the work stated above failed to commence within six (6) months from
date of issuance

NG

EO Q. GLEPA
icipal Mayor

thin six (6) months from