Dutchess County, NY · Dutchess County
Application for Approval of <5 GPM Well
Dutchess County property owners, engineers, or developers use this application to request approval for a well with a yield under five gallons per minute.
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
Use this application to seek Dutchess County Health Department approval for a well with a yield below 5 GPM. It collects owner and well details, pump-test and equipment information, and a certification; include pump-test results on page two and attach the manufacturer's pump curve or provide the requested pump-capacity details.
Who needs it
A property owner, engineer, or developer seeking approval for a well with a yield below 5 GPM should complete and submit this application.
How to submit it
Complete Sections A through C and mail the application to the Dutchess County Health Department, 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.
About notarization
This application is signed and dated without a notary; the owner, engineer, or developer certifies the information and installation.
How to submit this form
- 1
Download the Application
Download the Application for Approval of <5 GPM Well PDF.
- 2
Complete Sections A Through C
Fill in the owner, well, pump, and equipment information, then complete the certification.
- 3
Record Pump-Test Results
Enter pump-test results on the back of the form; attach an additional page if necessary.
- 4
Gather Pump Information
Attach the manufacturer's pump curve or complete the form's requested pump-capacity details.
- 5
Mail the Application
Mail the completed application to the Dutchess County Health Department at the address printed on the form.
Frequently asked questions
- Do I need a notary for the Application for Approval of <5 GPM Well?
- No. The form has a certification signature and date line, but no notary block; the owner, engineer, or developer signs and dates it.
- How do I submit the well approval application?
- Complete Sections A through C and mail the form to the Dutchess County Health Department at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601.
- What information does the application request?
- It asks for owner and well details, pump-test results, pump and tank information, and a certification. Pump-test results go on the back of the form.
- Do I need to include a pump curve?
- The form says to attach the manufacturer's pump curve or complete the requested pump-capacity details. Attach an additional page for pump-test results if necessary.