FEE $53.00
1 July 2015 – 30 June 2016
GST exempt
FORM NO. GEN 04v6
APPLICATION FOR PERMIT FOR A WATER AFFECTING ACTIVITY
Erection, construction or enlargement of a dam, wall or other structure that will
collect or divert water
Pursuant to Section 135 of the Natural Resources Management Act 2004
1.0 Applicant details
Name(s) in full: _____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
If body corporate: ACN__________________________________________________________
Contact address: ____________________________________________________________________
_________________________________________________________________________________
Contact name: _____________________________________________________________________
Telephone: ______________________________________________________________________
Mobile: __________________________________ Fax:______________________________________
It is an offence to provide information on this form that is false or misleading in a material particular
and may result in this application being refused.
Failure to provide complete details or pay the fee will delay processing of this application.
2.0 Proposed works
2.1 Do you propose to construct a new dam?  Yes
 No
If YES please specify proposed capacity of the dam
Capacity calculation guide
kilolitres
Volume in kL =
Area (m2) x depth (m) x 0.4
(kL)
If NO
and you propose to:
enlarge an existing dam go to Part 2.2
undertake other works go to Part 2.3
2.2 If you propose to enlarge an existing dam, specify the current and proposed volume of the dam
Current capacity
kL
Proposed capacity
kL
2.3 If you propose other works, detail in the space provided
2.4 Contractor name:
Phone no:
For office use only
Application no.
Receipt no.
Invoice no.
Batch no.
Date received _____________
Amount paid $_____________
Catchment _________________________
Application for permit for a water affecting activity
page 1 of 4
3.0 Property details
Describe the property on which dam works will be undertaken, being land that the applicant has a legal
entitlement to use in the proposed manner
3.1
Title reference
Allotment number
Plan number
Section
Hundred
Volume and folio number
3.2 Property address:
3.3 Property identifier e.g. CFS plate, property name:
4.0 Construction details
4.1 Will the dam be located  Onstream?  Offstream?
(see fact sheet for definition of onstream and offstream dams)
4.2 If water is to be diverted to the dam please specify the proposed method of diversion
 weir structure and pumping
 weir structure and diversion channel
 other
4.3 How high will the dam wall be?
metres
4.4 How deep will the dam be when it is full?
metres
4.5 What will be the approximate surface area of the dam when full?
square metres, hectares
(strike out non-applicable)
4.6 Will the dam have a spillway/ pipe (strike out non-applicable) through the dam wall?
5.0 Catchment area supplying water to the dam
5.1 What area of land will supply water to the proposed dam?
(a) from your property:
hectares
(b) from above your property:
hectares
6.0 Proposed water use
Please tick whichever applies:
 Irrigation
 Stock and domestic
Number and type of stock
 Environmental
Details
 Industrial
Type of industry
 Other
Details
Application for permit for a water affecting activity
Area (ha)
Crop type
page 2 of 4
7.0 Existing dam information
7.1 Are there any existing dams on your property?  Yes  No
If Yes please complete the table below. If No please go to Part 8.0
Purpose of water use for each dam
Dam capacity
Irrigation
(specify area & crop
(kL)
type)
Stock and domestic
Environmental
Industrial
(number & type of
stock)
(provide details)
(specify type of
industry)
If other please provide details below
8.0 Property plan and any other relevant information
Draw a plan of your property showing:
• property boundaries and buildings
• other significant features such as houses, sheds, tress and adjoining roads
• all watercourses and streams
• the precise location of the proposed dam and existing dams on the property with approximate distances to property
boundaries
• north point.
Attach another sheet if you need more space.
Application for permit for a water affecting activity
page 3 of 4
9.0 Other approvals
What, if any, approvals do you or your company have from other state or local government agencies
to construct or enlarge the proposed dam?
10.0 Signed by the applicant
The applicant must complete one only (1 or 2) of the following alternatives.
I/we declare that the information provided on this application is true and correct.
Signed:
1. Where the applicant is an individual or two or more persons
Sign here
Print name
Date
Sign here
Print name
Date
2. Where the applicant is a company or an incorporated association
Either
The seal of
)
)
)
)
)
___________________________________________________________
[name of company or incorporated association]
was hereby affixed in the presence of
_____________________________________________
_____________________________________________
_____________________________________________
Date_____________
[print names and positions held, sign and date]
or
___________________________________________________________
___________________________________________________________
[print name(s)]
a person or persons duly authorised to sign for and on behalf of
____________________________________________________________________
[name of company or incorporated association]
____________________________________________
____________________________________________
Date______________
[Sign]
Return application and payment to:
Attn: NRM Officer – Water
Kangaroo Island Natural Resources Management
Board
Reply Paid 665
Kingscote SA 5223
Enquiries: KI Natural Resources Management Board, 35 Dauncey Street, Kingscote, 8553 4300
Application for permit for a water affecting activity
page 4 of 4