Public Water Supply Protection Forms


Form Title Printable PDF Word Excel Support
DOH-347 Application for Approval of Backflow Prevention Devices PDF - - -
DOH-348 Application for Approval of Plans for Public Water Supply Improvements PDF Word Excel -
DOH-349 Application for Certificate of Approval for Bottled or Bulk Water Facilities PDF - - -
DOH-350 Application for Certificate of Waiver From Disinfection Requirements PDF - - -
DOH-352 Application for Renewal of Certification (Water Treatment Plant or Distribution System Operator) PDF - - -
DOH-2249 Plan Review Fee Determination Schedule PDF - - -
DOH-4301 Lead and Copper Materials Certification Form and Application for Waiver from Lead and Copper Sampling PDF - - -
DOH-4345 Specific Waiver Application Residential On-Site Water Supply Systems New or Replacement PDF - - -
DOH-4346 Specific Waiver Application Residential On-Site Watewater Treatment Systems PDF - - -
DOH-5009 Application for Approval of Sanitary Facilities for a Single Lot in an Unapproved Realty Subdivision PDF - - -
DOH-5025 Engineer's Certification of Public Water Improvement Project Completion PDF - - -
DOH-5205 Engineer's Certification of Technical Requirements for Design of Ultraviolet (UV) Facilities for Disinfection of a Public Water Supply PDF - - -


Form Title Printable PDF Word Excel Support
DOH-357a Bottled Water Monthly Operation Report (7/2016) PDF - - -
DOH-357b Bulk Water Monthly Operation Report (7/2016) PDF - - -
DOH-359 Annual Report on Violations of Watershed Rules and Regulations PDF - - -
DOH-360 Water Systems Operation Report - Microbiological Sample Results PDF Word Excel -
DOH-360CFL Water System Operation Report - For Use by Public Water Systems that Treat with Chlorine and/or Fluoride PDF Word Excel
DOH-360CUV Water Systems Operation Report - For Systems the Treat with Chlorine and/or Ultraviolet Radiation PDF - - -
DOH-1013 Report on Test and Maintenance of Backflow Prevention Device PDF - - -
DOH-1327 Percolation Test Data PDF - - Instructions included with DOH-1327 download
DOH-4204 Designation of Water Operator in Responsible Charge PDF - - -
DOH-4303 Water Systems Operations Report PDF - Excel -
DOH-4344 Drinking Water State Revolving Fund Pre-Application PDF - - -
DOH-5197 Revised Total Coliform Rule: Level 1 Assessment Form PDF - - -
DOH-5222 Environmental Assessment of Water Systems in Healthcare Settings PDF - - -

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