Form Doh-348 Application For Approval Of Plans For Public Water Supply Improvement - New York State Department Of Health

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NEW YORK STATE DEPARTMENT OF HEALTH
Application for Approval of Plans
for Public Water Supply Improvement
Bureau of Water Supply Protection (Ph. 518-402-7605)
1. Applicant:
2. Location of works:
3. County:
4. Water District:
(C,V,T)
(specific area served)
MONROE
5.Type of ownership:
Industrial
Private-Institutional
Board of Education
Federal
Municipal
Commercial
Private-Other
Authority
State
6. Nature of Project:
New Works.
If checked, provide capacity development (viability) analysis*
Modifications to existing System.
If checked, provide PWS ID# NY ____ ____ ____ ____ ____ ____ ____
7. Estimated Project Cost:
Source
$__________
Treatment
$____________
Storage
$____________
Distribution
$_______________
Pumping
$__________
Engineering
$____________
Legal/Permitting
$____________
Total
$_______________
Funding Source:
Private
DWSRF**
Federal
Other______________
If DWSRF is checked, provide DWSRF # ____ ____ ____ ____ ____
8. Type of Project:
Corrosion Control
U.V. Light Disinfection
Distribution
Source
Pumping Unit
Fluoridation
Storage
Transmission
Chlorination
Other Treatment
Other
9. Project Description: _________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
10. Latest total consumption data (in MGD):
Avg. day ________________________
Year ______________
Total Population of service area:
______________________
Max. day ________________________
Year ______________
% population actually served:
______________________
Peak hr. ________________________
Year ______________
% population served affected by project: ______________________
11.
12. NYS Professional
Name of Design Engineer: ________________________________
Licensed Engineer
Stamp & Signature***
NYS License No.:
________________________________
Firm:
_______________________________________________
Address: _______________________________________________
Return approved plans to:
E-Mail: _______________________________________________
Engineer
Tel. No.: ____________________ Fax. No.:___________________
Applicant
13. Applicant and Representative Information:
Name: _______________________________________________ Title: _____________________________________________________
Address: _________________________________________________________________________________________________________
____________________________________________________________
________/________/________
Signature of applicant
Date
NOTE: All applicants must be accompanied by 3 sets of plans, 3 sets of applications and an Engineer’s Report describing the project in detail.
The project must first be discussed with the appropriate city, county, district or regional public health engineer. Signature by a designated
representative must be accompanied by a letter of authorization.
* Additional information regarding capacity development may be found at:
** Current DWSRF project listings may be found at:
*** By affixing the stamp and signature the Design Engineer agrees that the plans and specifications have been prepared in accordance with the most recent
version of Recommended Standards for Water Works in accordance with the NYS Sanitary Code.
DOH-348 (7/06)
Monroe County Version - Water Supply Section (Ph. 585.753.5057)

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