Public Water Supply Protection Forms
Applications
| Form | Title | Printable PDF | Word | Excel | Support Documents |
|---|---|---|---|---|---|
| DOH-347 | Application for Approval of Backflow Prevention Devices | - | - | - | |
| DOH-348 | Application for Approval of Plans for Public Water Supply Improvements | Word | Excel | - | |
| DOH-349 | Application for Certificate of Approval for Bottled or Bulk Water Facilities | - | - | - | |
| DOH-350 | Application for Certificate of Waiver From Disinfection Requirements | - | - | - | |
| DOH-352 | Application for Renewal of Certification (Water Treatment Plant or Distribution System Operator) | - | - | - | |
| DOH-2249 | Plan Review Fee Determination Schedule | - | - | - | |
| DOH-4301 | Lead and Copper Materials Certification Form and Application for Waiver from Lead and Copper Sampling | - | - | - | |
| DOH-4345 | Specific Waiver Application Residential On-Site Water Supply Systems New or Replacement | - | - | - | |
| DOH-4346 | Specific Waiver Application Residential On-Site Watewater Treatment Systems | - | - | - | |
| DOH-5009 | Application for Approval of Sanitary Facilities for a Single Lot in an Unapproved Realty Subdivision | - | - | - | |
| DOH-5025 | Engineer's Certification of Public Water Improvement Project Completion | - | - | - | |
| DOH-5205 | Engineer's Certification of Technical Requirements for Design of Ultraviolet (UV) Facilities for Disinfection of a Public Water Supply | - | - | - |
Reports
| Form | Title | Printable PDF | Word | Excel | Support Documents |
|---|---|---|---|---|---|
| DOH-357a | Bottled Water Monthly Operation Report (7/2016) | - | - | - | |
| DOH-357b | Bulk Water Monthly Operation Report (7/2016) | - | - | - | |
| DOH-359 | Annual Report on Violations of Watershed Rules and Regulations | - | - | - | |
| DOH-360 | Water Systems Operation Report - Microbiological Sample Results | Word | Excel | - | |
| DOH-360CFL | Water System Operation Report - For Use by Public Water Systems that Treat with Chlorine and/or Fluoride | Word | Excel | ||
| DOH-360CUV | Water Systems Operation Report - For Systems the Treat with Chlorine and/or Ultraviolet Radiation | - | - | - | |
| DOH-1013 | Report on Test and Maintenance of Backflow Prevention Device | - | - | - | |
| DOH-1327 | Percolation Test Data | - | - | Instructions included with DOH-1327 download | |
| DOH-4204 | Designation of Water Operator in Responsible Charge | - | - | - | |
| DOH-4303 | Water Systems Operations Report | - | Excel | - | |
| DOH-4344 | Drinking Water State Revolving Fund Pre-Application | - | - | - | |
| DOH-5197 | Revised Total Coliform Rule: Level 1 Assessment Form | - | - | - | |
| DOH-5222 | Environmental Assessment of Water Systems in Healthcare Settings | - | - | - |
Reference Material
| Title | Subject |
|---|---|
| Recommended Standards For Water Works, 2018 Edition | "10 States" Policies for the Review and Approval of Plans and Specifications for Public Water Supplies |
To receive hard copies of these forms, please contact:
Center for Environmental HealthBureau of Water Supply Protection
Empire State Plaza-Corning Tower, Room 1110
Albany, New York 12237
