Form of Application to be made for Construction, Establishment

or Installation of Factory, Workshop or Workplace in which Steam

or other power is to be employed
1. Name and address pf the applicant -

2. Name and address of owner of the land -

3. Whether consent of the owners of the land obtained and if -

so, copy of the same
4. Details of the site:-

Taluk Village Sy.No. Extent

Boundaries
East
South
West
North
5. Maximum number of workers proposed to be employed on -
any day in the factory, workshop or workplace or premises
6. Distance between in the site and residential buildings within -
100 meters
7. Whether the site is in any industrial area approved by the -
industrial Department
8. Distance from the nearest source of community water -
supply
9. Whether the plan of the site and the building if any -
proposed to be constructed has been submitted
10. Particulars as to the power machinery or plant proposed to -
be installed (details of each machinery to be shown
separately)
11. Whether the location of machinery has been shown in the -
building plan
12. Details of raw materials & Chemicals to be used -
13. Manufacturing process -
14. Details of wastes and effluents expected from the factory -
with quantity
15. Facilities made for the disposal of all kinds of waste from -
the Factory without causing any water pollution or any
other public health nuisance
16. Scope for future expansion of factory (indicate whether -
there is sufficient space for expansion of the Factory in
future, if there is scope for the same
17. Amount of permission fee paid -

Date: Signature of the Applicant