Infrastructure Services
Shire of Yarra Ranges
P.O. Box 105
LILYDALE VIC 3140
Telephone: 1300 368 333
mail@yarraranges.vic.gov.au
APPLICATION FOR RESIDENT FUNDED DUST SUPPRESSANT
Applicant’s Name:
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Applicant’s Address:
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Home: ............................... Work: ................................ Mobile: ......................................
 YES
Is this application made on behalf of a group of residents
 NO
If YES, please provide details of other contributors to this application :
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Road to be treated ...............................................................................................................
Section of Road Requiring Dust Suppressant (from and to details)
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Treatment Length: ......................................
(must be 100 metres or greater)
Payment Enclosed: ......................................
(payment to be sent with application)
Please draw a plan of the road (on the reverse side of this application form) clearly showing
the section of road to be treated (using references such as house numbers, driveways, fence
lines, road features, etc to enable ready identification of the section to be treated)
FOR CASHIER USE ONLY
To be receipted to cost centre: 900325-1612
Receipt and application paperwork to be forwarded to the Infrastructure Services Department – AS SOON
AS POSSIBLE for processing.
Plan of Road (showing section of road requiring treatment)
Any further information relating to this application: .....................................................................................................................................
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Cost:100 metres - $330
200 metres - $660
300 metres - $990
Etc.
PLEASE ENSURE THAT ALL DETAILS ON THIS FORM ARE COMPLETED
AND RETURNED TO YARRA RANGES COUNCIL PRIOR TO THE
END OF NOVEMBER