B
REGISTRATION/LICENSING PART 1
/COMPANY, BUSINESS OR PARTNERSHIP;
/NATIONAL OR PROVINCIAL GOVERNMENT
a) New registration / b) Minor change / c) Formal amendment / d) Successor in titleReg. No. / Reg. No.
1. PARTICULARS OF APPLICANT
Application for / a) Company, business or partnership / (complete part 2, 4, 5, 6, 7 and 8)
(mark one with X): / b) National or Provincial Government / (complete part 3, 4, 5, 6, 7 and 8)
2. PARTICULARS OF COMPANY, BUSINESS OR PARTNERSHIP
2.1 / Name of company, business or partnership
2.2 / Trading name if different from name of company, business or partnership
2.3 / Business Registration Number
2.4 / a) Date Established / b) Country where established
Y / Y / Y / Y / M / M / D / D
3. PARTICULARS OF NATIONAL OR PROVINCIAL GOVERNMENT
3.1 / National Department
3.2 / a) Province
b) Provincial Department
4. CONTACT DETAILS
4.1 / Postal Address
Postcode
4.2 / Street Address (only if different from postal address)
4.3 / Contact telephone number during office hours
Area/cell code / Number / Ext.
Alternative contact number
Area/cell code / Number / Ext.
5. PROPERTY WHERE WATER USE OCCURS
5.1 / Property where water use takes place (farm, stand or community: description as per the Deeds Act if applicable)
5.2 / If the property is unsurveyed, complete the following:
a) Magisterial District or Local Authority
b) Surname and initials of leader of village, community or tribal authority / Initials
5.3 / If the property has been surveyed, complete the following:
a) Deeds Office
b) / Administrative District / or / Registration Division
c) Farm Number / d) Portion of property
e) Title Deed Number
1 / 2 / 3 / 4 / 5
f) Surveyor-General Cadastral Code / - / - / - / -
1. Province
2. Major Code (Registration Division)
3. Minor Code
4. Farm Number/ Erf Number/ Holding Area Number/ Scheme Number
5. Portion Number
Note: All fields “left padded with 0”
5.4 / Property Area Size
ha
5.5 / Ownership of the property (mark only one with X )
a) / Property owned by applicant / b) / Property leased by applicant / c) / The property is communal land
If the applicant leases the property, the owner must sign the declaration section below (section 8)
6. DETAILS OF THE PROPERTY OWNER
6.1 / Nature of the property owner (mark only one)
Person / Company* / National Government / Provincial/ Local Government
6.2 / Identification Number (if applicable) / (e.g. ID Number, Business Register Number)
Country of issue of identification if a foreign ID. / Expiry Date
6.3 / Surname or name of owner
6.4 / Initials (if applicable) / Title (if applicable)
6.5 / If the property owner is a company:
Trading name if applicable and different from name of company, business or partnership
Date Established / Y / Y / Y / Y / M / M / D / D
Country where established
6.6 / Postal Address
Postcode
6.7 / Street Address (only if different from postal address)
6.8 / Contact telephone number during office hours
Area/cell code / Number / Ext.
Alternative contact number
Area/cell code / Number / Ext.
* public company, private company, company not for gain, guarantee company, external company, incorporated private company, closed corporation
7. DECLARATION BY APPLICANT
7.1 / Surname of delegated person
Initials / Title / ID Number
7.2 / If not holder of South African ID: passport no / Expiry Date / Y / Y / Y / Y / M / M / D / D
Country of issue
7.3 / Position or official status
7.4 / I declare that the information given by me in registering water use is true and correct.
Signature / Date
Thumbprint
(only if
requested)
Y / Y / Y / Y / M / M / D / D
8. DECLARATION BY PROPERTY OWNER (if not the applicant) /
8.1 / Property owner or delegated person:
Surname
Initials / Title / ID Number
8.2 / If not holder of South African ID: passport no. / Expiry Date / Y / Y / Y / Y / M / M / D / D
Country of issue
8.3 / Position or official status
8.4 / I declare that the applicant defined in paragraph 1 (above) has lawful access to occupy the property and carry out
the water use activity or activities set out in paragraph 2.
Signature
Date / Thumbprint
Y / Y / Y / Y / M / M / D / D / (only if
requested)
9. FOR OFFICIAL USE ONLY
9.1 PART 2 FORMS ATTACHED:DW760 / 21(a) Taking water / DW766 / 21(f) Discharging waste, pipe …
DW773 / 21(a) Taking water / DW778 / 21(f) Discharging waste, pipe …
DW761 / 21(b) Storing water / DW767 / 21(g) Disposing of waste
DW774 / 21(b) Storing water / DW779 / 21(g) Disposing of waste
DW762 / Dam registration / DW808 / Waste disposal facility registration
DW763 / 21(c) Impeding / diverting flow / DW805 / 21(j) Removing underground water
DW775 / 21(c) Impeding / diverting flow / DW782 / 21(j) Removing underground water
DW764 / 21(d) SFRA / DW806 / 21(k) Recreational use
DW776 / 21(d) SFRA / DW783 / 21(k) Recreational use
DW765 / 21(e) Controlled activity / DW768 / 21(i) Altering beds and banks
DW777 / 21(e) Controlled activity / DW781 / 21(i) Altering beds and banks
WMA for billing *
* Water management area codes
01 / Limpopo / 05 / Inkomati / 09 / Middle Vaal / 13 / Upper Orange / 17 / Olifants/Doorn
02 / Luvuvhu, Letaba / 06 / Usutu-Mhlatuze / 10 / Lower Vaal / 14 / Lower Orange / 18 / Breede
03 / Crocodile(W),Marico / 07 / Thukela / 11 / Mvoti-Umzimkulu / 15 / Fish-Tsitsikamma / 19 / Berg
04 / Olifants / 08 / Upper Vaal / 12 / Mzimvubu-Keiskamma / 16 / Gouritz
9.3 LIST OF ATTACHED DOCUMENTS (Mark each document attached with X) /
9.3.1 / Certified copy of identity document (paragraph 7.1 & 8.1) or passport (paragraph 7.2 & 8.2)
9.3.2 / Certified copy of property deed (paragraph 5.3)
9.3.3 / Certified copy of lease agreement (paragraph 5.5)
File Number
Received by:
Surname / Initials
Rank
Signature
Captured by:
Initials
Date stamp of receiving office
Allocated Reg. No.Version 1 2003-09-22 / p 1 of 4