Orange County, NY · Orange County
Application for Approval of Backflow Prevention Devices
Facility owners and applicants use this application to seek approval for proposed backflow prevention devices from the Orange County Department of Health.
At a glance
- Issued by
- City of Orange County · Orange County, Orange County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- orangecountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This application requests approval for backflow prevention devices at a facility and identifies whether the work involves an initial installation or replacement. It asks for facility and applicant details, device specifications and locations, hazard information, project costs, water system pressure, and water supplier information. Submit it first to the water supplier with plans, specifications, a review fee, and an engineer’s report; the supplier completes its sections and forwards it to the department.
Who needs it
Facility owners or applicants proposing backflow prevention devices submit this application through their water supplier for department review.
How to submit it
Submit the application first to the water supplier, which completes Sections 11 and 11a and forwards it to the Orange County Department of Health, 124 Main Street, 3rd Floor, Goshen, NY 10924. Include plans, specifications, a review fee, and an engineer’s report.
About notarization
This application is signed without a notary; the design engineer or architect must provide an original ink signature and seal on all copies, and the water supplier representative signs.
How to submit this form
- 1
Download the Application
Download the application for approval of proposed backflow prevention devices.
- 2
Complete the Application
Print or type all entries except signatures, and provide facility, applicant, device, project, and water supplier details.
- 3
Gather Required Materials
Include plans, specifications, a review fee, and an engineer’s report describing the project in detail.
- 4
Submit to the Water Supplier
Submit the application to the water supplier first. The supplier completes Sections 11 and 11a and forwards it to the Orange County Department of Health.
Frequently asked questions
- What is the backflow prevention device application for?
- It requests approval for proposed backflow prevention devices at a facility and collects project, device, applicant, engineer, and water supplier information.
- Who submits this application?
- A facility owner or applicant seeking approval for proposed backflow prevention devices submits the application first to the water supplier.
- How do I submit the backflow prevention device application?
- Submit it to the water supplier first, with plans, specifications, a review fee, and an engineer’s report. The supplier completes Sections 11 and 11a and forwards it to the Orange County Department of Health.
- Do I need a notary for the backflow prevention device application?
- No. The application is signed without a notary; the design engineer or architect must provide an original ink signature and seal on all copies, and the water supplier representative signs.