NEW YORK STATE DEPARTMENT OF HEALTH
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Public Water Supply Protection
Application for Approval of Backflow Prevention Devices
PRINT OR TYPE ALL ENTRIES EXCEPT SIGNATURES Please completed items 1 through 12a + Block and Lot Numbers
1. Name of Facility
Block #
Lot #
2. City, Village, Town
FOR DEPARTMENT USE ONLY Log No.
3. County
Street
4. Location of Facility
4a. Phone Numbers
City
state
zip
5. Contact Person
5. Approx. Location of Device(s)
6. Mfg. Model #
Size of Device(s)
# of Fire Services
# of Domestic Services
# of Combined Services Total # of Services
Total # of Buildings
7. Name of Owner
Full Mailing Address Address
City
Owner's Signature
Title
street
Phone Number
state
zip
8. Nature of works Initial Device Installation Replace Existing Device
8a. New Service Existing Service
8b.
Date _____/_____/_____ M D Y
New Building Existing Building Major Renovations
9. Name of Design Engineer or Architect
Street
Address
City
State
Zip
10. NYS License #
PE
RA
Other
10a. Telephone Number(s)
Original Ink signature and seal required on all copies
11. Water System Pressure (psi) at Point of Connection
Signature
Date
_____/_____/_____
M D
Y
12. Estimate Installation Cost 12a. Estimate Design Cost
Max ________ Avg ________ Min ________
13. Degree of Hazard
List of processes or reasons that lead to degree of hazard checked:
Hazardous Aesthetically Objectionable
14. Public water supply name
Name of supplier's designate representative
Mailing Address
Title
___________________________________________________
street
_____________________________________________________
____________________________________________________________________
City
state
zip
Telephone No. ( )
Signature _________________________ _____/_____/_____
M D
Y
Note: All applicants must be accompanied by plans, specifications and an engineer's report describing the project in detail. The project must first be submitted to the water supplier, who will forward it to the local public health engineer. This form must be prepared in quadruplicate with four copies of all plans, specifications and descriptive literature.
DOH-347 (5/91)
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