How do I submit the waiver request form?

Complete Sections A, B, and C, then submit the form to the Dutchess County Department of Health at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.

What information does the form request?

It asks for public water supply and project information, a description of the requested waiver, and a justification. The owner also provides a name, title, signature, and date.

Do I need to attach sample results?

Attach copies of past sample results if those results are the basis for the waiver request.

Dutchess County, NY · Dutchess County

No notary required

Sampling Requirement or Treatment Technique Waiver Request Form

Public water supply owners or operators use this form to request a waiver from a sampling requirement or treatment technique from Dutchess County.

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: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

This form requests a waiver from a sampling requirement or treatment technique for a public water supply. The owner or operator provides project and water supply information, describes the waiver requested, and explains the justification. The owner signs and dates the request; if past sample results support it, copies of those results should be attached.

Who needs it

Owners or operators of public water supplies seeking a waiver from a sampling requirement or treatment technique need to complete this form.

How to submit it

Complete Sections A, B, and C and submit the form to the Dutchess County Department of Health, 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.

About notarization

The owner signs and dates this form without a notary; attach past sample results only if they are the basis for the waiver request.

How to submit this form

1
Download the Form
Download the Sampling Requirement or Treatment Technique Waiver Request Form.
2
Complete Sections A, B, and C
Enter the public water supply and project information, explain the waiver request and justification, then provide the owner's signature and date.
3
Gather Sample Results
Attach copies of past sample results if they are the basis for the waiver request.
4
Submit to the County
Submit the completed form to the Dutchess County Department of Health at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.

Frequently asked questions

Do I need a notary for the Sampling Requirement or Treatment Technique Waiver Request Form?: No. The owner signs and dates this form without a notary. Attach past sample results only if they are the basis for the waiver request.
How do I submit the waiver request form?: Complete Sections A, B, and C, then submit the form to the Dutchess County Department of Health at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.
What information does the form request?: It asks for public water supply and project information, a description of the requested waiver, and a justification. The owner also provides a name, title, signature, and date.
Do I need to attach sample results?: Attach copies of past sample results if those results are the basis for the waiver request.

Need something notarized?

This Sampling Requirement or Treatment Technique Waiver Request Form doesn’t need a notary, but if you have another Dutchess County form that does, a commissioned online notary can help.