Dutchess County, NY · Dutchess County
Waiver Request Form
Engineers use this form to request a specific waiver from a health standard for a project and provide the property owner’s authorization.
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
The form lets an engineer request a specific waiver and explain the project, the standard involved, and why the waiver would not compromise public health. The engineer completes Sections A and B, and the property owner or someone with legal authority signs Section C and attaches authorization. Projects with a surface discharge are not eligible for a waiver.
Who needs it
An engineer requesting a specific waiver for a project needs this form, along with the property owner’s signature or authorization from someone legally authorized to apply.
How to submit it
Submit the completed form to the Dutchess County Health Department, 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601; the form also lists fax number 845-486-3545.
About notarization
This form is signed and dated without a notary; the engineer and owner sign it, and the owner attaches authorization.
How to submit this form
- 1
Download the Form
Download the Waiver Request Form for the project.
- 2
Complete Project Information
Have the engineer complete Sections A and B with project details, the requested waiver, and site-specific justification.
- 3
Attach Owner Authorization
Have the property owner or a legally authorized person sign Section C and attach authorization.
- 4
Submit to the County
Submit the completed form to the Dutchess County Health Department at the address shown on the form.
Frequently asked questions
- What is the Waiver Request Form for?
- It is used to request a specific waiver from a health standard for a project and provide project details and engineering justification.
- Who completes and signs the waiver form?
- The engineer completes Sections A and B. The property owner, or someone with legal authority to apply, signs Section C and attaches authorization.
- Do I need a notary for the Waiver Request Form?
- No. The engineer and owner sign and date this form; the owner must attach authorization. The form does not require notarization.
- How do I submit the Waiver Request Form?
- Submit it to the Dutchess County Health Department at 85 Civic Center Plaza, Suite 106, Poughkeepsie, NY 12601. The form also lists a fax number.