Public Water Supply Protection Forms

Applications

Form Title  Printable PDF  Word Excel Support
Documents
DOH-347 Application for Approval of Backflow Prevention Devices PDF (11KB, 1pg.) - - -
DOH-348 Application for Approval of Plans for Public Water Supply Improvements PDF (33KB, 1pg.) Word (63KB, 1pg.) Excel (38KB) -
DOH-349 Application for Certificate of Approval for Bottled or Bulk Water Facilities PDF (503KB, 1pg.) - - -
DOH-350 Application for Certificate of Waiver From Disinfection Requirements PDF (67KB, 2pg.) - - -
DOH-352 Application for Renewal of Certification (Water Treatment Plant or Distribution System Operator) PDF (70KB, 2pg.) - - -
DOH-2249 Plan Review Fee Determination Schedule PDF (58KB, 1pg.) - - -
DOH-4301 Lead and Copper Materials Certification Form and Application for Waiver from Lead and Copper Sampling PDF (35KB, 1pg.) - - -
DOH-4345 Specific Waiver Application Residential On-Site Water Supply Systems New or Replacement PDF (249KB, 2pg.) - - -
DOH-4346 Specific Waiver Application Residential On-Site Watewater Treatment Systems PDF (245KB, 2pg.) - - -
DOH-5009 Application for Approval of Sanitary Facilities for a Single Lot in an Unapproved Realty Subdivision PDF (139KB, 1pg.) - - -
DOH-5025 Engineer's Certification of Public Water Improvement Project Completion PDF (55KB, 1pg.) - - -

Reports

Form Title Printable PDF Word Excel Support
Documents
DOH-357 Production Bacteriological Samples, Rev 9-2012 PDF (198KB, 2pg.) - - -
DOH-359 Annual Report on Violations of Watershed Rules and Regulations PDF (1MB, 2pg.) - - -
DOH-360 Water Systems Operation Report - Microbiological Sample Results PDF (218KB, 2pg.) Word (240KB) Excel (58KB) -
DOH-360CFL Water System Operation Report - For Use by Public Water Systems that Treat with Chlorine and/or Fluoride PDF (245KB, 2pg.) Word (255KB) Excel (58KB)
DOH-360CUV Water Systems Operation Report - For Systems the Treat with Chlorine and/or Ultraviolet Radiation PDF (228KB, 3pg.)   Excel (58KB) -
DOH-1013 Report on Test and Maintenance of Backflow Prevention Device PDF (22KB, 2pg.) - - -
DOH-1327 Percolation Test Data PDF (44KB, 2pg.) - - Instructions included with DOH-1327 download
DOH-4204 Designation of Water Operator in Responsible Charge PDF (25KB, 1pg) - - -
DOH-4303 Water Systems Operations Report PDF (90KB, 3pg.) - Excel (79KB) -
DOH-4344 Drinking Water State Revolving Fund Pre-Application PDF (132KB, 2pg.) - -

Order Forms

Title Subject Order Information
Recommended Standards For Water Works, 2007 Edition (HTML version) "10 States" Policies for the Review and Approval of Plans and Specifications for Public Water Supplies Hard copy available through Health Research, Inc.

To receive hard copies of these forms, please contact:

Center for Environmental Health
Bureau of Water Supply Protection
Empire State Plaza-Corning Tower, Room 1110
Albany, New York 12237