Who should use the ultraviolet disinfection system application?

Owners requesting approval to install an ultraviolet disinfection system for an eligible non-community water supply using groundwater can use this application. It is limited to groundwater sources without an external distribution system.

What should I include with the application?

Submit required water test results from a New York State Department of Health certified laboratory and complete the treatment system schematic. If you propose a configuration other than the one shown, attach an appropriate sketch.

How do I submit the ultraviolet disinfection application?

Submit the completed application with the required water test results and schematic. The document directs applicants to provide the materials to the Orange County Department of Health but does not give a specific delivery address or submission method.

Do I need a notary for the ultraviolet disinfection application?

No. The owner signs and dates the application; it does not identify any attachment or related step that must be notarized or sworn.

Orange County, NY · Orange County

No notary required

Ultraviolet Disinfection System Installation Approval Application

This application is for owners seeking Orange County Department of Health approval to install an ultraviolet disinfection system on an eligible groundwater supply.

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

What this form is

Use this application to request approval for an ultraviolet disinfection system serving a non-community water supply from a groundwater source. The form is for eligible systems without an external distribution system; it asks about the facility, owner, water system, well, and proposed treatment equipment. Submit the completed application with required water test results and a system diagram; include a sketch if proposing a different configuration.

Who needs it

Owners seeking approval for an ultraviolet disinfection installation on an eligible groundwater supply must complete and submit this application.

How to submit it

Submit the completed application with required water test results from a New York State Department of Health certified laboratory. Include the completed treatment system schematic and an appropriate sketch if proposing a different configuration.

About notarization

This document is signed and dated by the owner without a notary; the form does not identify any attachment or related step that must be notarized or sworn.

How to submit this form

1
Download the Application
Download the application for approval of an ultraviolet disinfection system installation.
2
Complete the Application
Provide facility and owner details, water system information, and the proposed treatment system details.
3
Gather Required Materials
Include required water test results from a certified laboratory and complete the treatment system schematic; attach a sketch for a different configuration.
4
Submit to the County
Submit the completed application and required materials to the Orange County Department of Health.

Frequently asked questions

Who should use the ultraviolet disinfection system application?: Owners requesting approval to install an ultraviolet disinfection system for an eligible non-community water supply using groundwater can use this application. It is limited to groundwater sources without an external distribution system.
What should I include with the application?: Submit required water test results from a New York State Department of Health certified laboratory and complete the treatment system schematic. If you propose a configuration other than the one shown, attach an appropriate sketch.
How do I submit the ultraviolet disinfection application?: Submit the completed application with the required water test results and schematic. The document directs applicants to provide the materials to the Orange County Department of Health but does not give a specific delivery address or submission method.
Do I need a notary for the ultraviolet disinfection application?: No. The owner signs and dates the application; it does not identify any attachment or related step that must be notarized or sworn.

Need something notarized?

This Ultraviolet Disinfection System Installation Approval Application doesn’t need a notary, but if you have another Orange County form that does, a commissioned online notary can help.