Hempstead, NY · Nassau County
Application for Approval of Backflow Prevention Devices
This application requests approval of backflow prevention devices and is completed by a facility owner and the project’s design engineer or architect.
What this form is
Use this form to request approval for a backflow prevention device installation, replacement, new service, existing service, new building, existing building, or major renovation. It asks for facility and owner details, device and service information, project costs, water pressure, and the degree of hazard. The application must include plans, specifications, and an engineer’s report describing the project.
Who needs it
Facility owners and their design engineer or architect complete the application for a proposed backflow prevention device project.
How to submit it
Submit the project first to the water supplier, which will forward it to the local public health engineer. Prepare four copies of the form and four copies of all plans, specifications, and descriptive literature.
About notarization
This document is signed without a notary; the owner signs and dates it, and the engineer provides an original ink signature and seal.
How to submit this form
- 1
Download The Application
Download the backflow prevention device approval application.
- 2
Complete The Form
Fill in the facility, owner, device, project, water pressure, cost, and hazard information.
- 3
Gather Supporting Materials
Prepare plans, specifications, and an engineer’s report describing the project; make four copies of each.
- 4
Submit To The Water Supplier
Submit the project first to the water supplier, which will forward it to the local public health engineer.
Frequently asked questions
- Do I need a notary for the backflow device approval application?
- No. The form has signature fields but no notary block; the owner signs and dates it, and the engineer provides an original ink signature and seal.
- How do I submit the backflow device approval application?
- Submit the project first to the water supplier, which will forward it to the local public health engineer. The form calls for four copies of the application and supporting materials.
- What must accompany the application?
- Include plans, specifications, and an engineer’s report describing the project in detail, with four copies of each.
Need something notarized?
This Application for Approval of Backflow Prevention Devices doesn’t need a notary — but if you have another Hempstead form that does, a commissioned online notary can help.