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-1024 | Application for Certification of Backflow Prevention Device Tester | PDF (14KB, 2pg.) | - | Instructions for Completing DOH-1024 | |
| 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-359 | Annual Report on Violations of Watershed Rules and Regulations | PDF (191KB, 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:
- NYS Department of Health
Bureau of Public Water Supply Protection
547 River Street
Flanigan Square, Room 400
Troy, NY 12180-2216
or call 518-402-7650 or 1-800-458-1158
