Form No. 6 ANDAMAN AND NICOBAR ADMINISTRATION DIRECTORATE OF FISHERIES * * * * APPLICATION FORM FOR FINANCIAL ASSISTANCE FOR CONSTRUCTION OF BRACKISH WATER POND 1) Name of applicant (in block letters) : 2) Father's name : 3) Permanent address : 4) Address for communication : 5) Area available (In hect.) : (i) Name of the village : (ii) Survey No. : (iii) Ownership detail : 6) Survey No. & Plot No. in which the pond will be constructed (Certified copies of documents from the Revenue authority showing the ownership details, in case of leased land enclosed copies of lease deed) 7) Elevation and Topography of site with respect to mean sea level. : 8) Description of water source and its distance from sea and water quality : 9) Soil characteristics : 10) Size of pond to be constructed (in hect.) : (a) Length : ....................... (b) Breadth : ....................... (c) Depth : ....................... 11) Estimated cost of construction (In Rs.) (Enclose detail Plan & Estimate) : 12) Time required for completion of work. : 13) Total cost of construction (In Rs.) : 14) Source of finance (In Rs.) : (a) Applicant contribution : (b) Assistance required from Government. : (c) Loan if any. : 15) Agency for construction, if local labourers are available, the number of labourers proposed to be availed and rate of earth work : 16) How the pond will be used after construction : 17) Type of fishes / other marine biota proposed for culture : 18) Whether any financial assistance was availed during any previous year for similar purpose, if so details there of. : 19) Whether the applicant is a defaulter to any scheme of Fisheries Department or any other department, if so furnish details : Certified that the information furnished above are true to the best my knowledge and belief and I shall be personally responsible, if any part of the information is found incorrect. Place : Dated : Signature of the Applicant Recommendation of the members of the respective Panchayati Raj Institution/ Counsellor of Municipal Ward (with name, signature, seal and date) For Office Use Only (i) Date of receipt of application (ii) Field verification report and specific recommendation of the Officer Incharge (with signature, date and seal) (i) Recommendation of Zonal Officer Incharge (with signature, date and seal) (iv) For use in the Directorate of Fisheries
