Dutchess County, NY · Dutchess County
Application for a Certificate of Waiver From Disinfection Requirement
Public water supply owners use this application to request a waiver from the disinfection requirement from the Dutchess County Department of Health.
At a glance
- Issued by
- City of Dutchess County · Dutchess County, Dutchess County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- dutchessny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This application is for an owner of a public water supply seeking a waiver from the disinfection requirement. It asks for system and owner details, prior waiver information, and answers about water samples, connections, nearby hazards, equipment, maintenance, pressure, and emergencies. The applicant can explain answers on the back and is asked to attach sample results if they were not previously submitted.
Who needs it
An owner of a public water supply seeking a waiver from the disinfection requirement should complete this application.
How to submit it
Send the completed application to the Dutchess County Department of Health, 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601; the form also lists telephone and fax numbers.
About notarization
This application is signed and dated without a notary; it mentions no related sworn or notarized step, so the signer just signs and dates it.
How to submit this form
- 1
Download the Application
Download the application for a Certificate of Waiver From Disinfection Requirement.
- 2
Complete the Application
Enter the public water supply and owner information, answer the questions, and sign and date the application.
- 3
Gather Sample Results
Attach sample results if they were not previously submitted. You may explain answers on the back of the form.
- 4
Send It to the County
Send the completed application to the Dutchess County Department of Health at the address shown on the form.
Frequently asked questions
- Do I need a notary for the disinfection waiver application?
- No. The application has a signature and date line but no notary block; it mentions no related sworn or notarized step.
- How do I submit the disinfection waiver application?
- Send it to the Dutchess County Department of Health at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601. The form also lists telephone and fax numbers.
- What information does the application ask for?
- It asks for public water supply and owner details, prior waiver information, and answers about water samples, system connections, hazards, equipment, water pressure, and emergencies.
- Do I need to attach water sample results?
- The form says to attach sample results if they were not previously submitted.