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Application for Approval of Plans for Public Water Supply Improvement NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Water Supply Protection Applicant Location of works (C,V,T) County Water District (specific area served) Type of ownership Private – Other Authority Interstate Municipal Commercial Private – Institutional Federal International Industrial Water Works Corp. Board of Education State Native American Reservation Modifications to existing system. If checked, provide PWS ID # NY New System. If checked, provide capacity development (viability) analysis* If this project involves a new system, new water district, or a district extension provide boundary description location details in digital format on CD or Floppy Disk. If digital boundary location details are not available provide a text description. Digital GIS Data Provided Digital CAD Data Provided Other Digital Data Provided Text Description Provided N/A Funding Source Private Federal If is checked, provide # Estimated Project Cost Source Treatment Storage Distribution Pumping Engineering Legal/Permitting Total Type of Project Corrosion Control U.V. Light Disinfection Distribution Source Pumping Unit Fluoridation Storage Transmission Chlorination Other Treatment Other Project Population Total population % population % population served of Service area actually served affected by project Latest total consumption data (in MGD) Avg. day Max. day Peak hr. 14. NYS Professional Licensed Engineer Stamp & Signature Name of design engineer Address Telephone No. E-Mail Fax No. Name and title of applicant or designated representative Address Signature of applicant Date NOTE: All applications must be accompanied by 3 sets of plans, 3 sets of specifications and an engineer’s report describing the project in detail. The project must first be discussed with the appropriate city, county, district or regional public health engineer. Signature by a designated representative must be accompanied by a letter of authorization. * Additional information regarding capacity development may be found at: http://www.health.state.ny.us/nysdoh/water/main.htm **Current project listings may be found at: http://www.health.state.ny.us/nysdoh/water/main.htm ***By affixing the stamp and signature the Design Engineer agrees that the plans and specifications have been prepared in accordance with the most recent version of the recommended standards for water works and in accordance with the NYS Sanitary Code. DOH-348 (02/05)