Doh 347 Form PDF Details

Ensuring the safety and integrity of public water supplies is a critical duty that falls upon various stakeholders, from local businesses to the New York State Department of Health. Within this context, the DOH-347 form serves as an essential instrument. This form, specifically designed by the Bureau of Public Water Supply Protection, is utilized to seek approval for the installation or replacement of backflow prevention devices. These devices are crucial in preventing contaminated water from flowing back into the public water system, thereby safeguarding the community's health. Applicants are required to provide comprehensive details, including the facility's name, location, and contact information, alongside technical specifics about the backflow prevention device such as the manufacturer, model number, and size. Additionally, the form delves into the nature of the installation—whether it pertains to a new service, a replacement, or major renovations—and requires information about the owner, design engineer or architect, and the estimated costs involved. The degree of hazard that the installation aims to mitigate is also a critical component, highlighting the significance of these devices in managing risks to the water supply. Plans, specifications, and an engineer’s report must accompany the form, emphasizing the thorough evaluation process undertaken to ensure compliance and safety. The DOH-347 form thus stands as a key document in the collaboration between business owners, engineers, and health departments to protect public health through the diligent management of water supply systems.

QuestionAnswer
Form NameDoh 347 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdoh 347 form, form doh 347, doh347, application backflow form

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH

Bureau of Public Water Supply Protection

Application for Approval of Backflow Prevention Devices

PRINT OR TYPE ALL ENTRIES EXCEPT SIGNATURES

Block #

Lot #

FOR DEPARTMENT USE ONLY

Please completed items 1 through 12a + Block and Lot Numbers

 

 

 

 

Log No.

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Name of Facility

 

2.

City, Village, Town

 

 

3.

County

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

City

 

state

 

zip

4.

Location of Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4a. Phone Numbers

 

5.

Contact Person

 

 

 

 

 

 

 

 

 

 

 

 

5.

Approx. Location of Device(s)

 

6.

Mfg. Model #

 

Size of Device(s)

 

 

 

 

 

 

 

 

 

 

 

# of Fire Services

# of Domestic Services

# of Combined Services

Total # of Services

Total # of Buildings

7. Name of Owner

 

Title

 

 

 

Phone Number

 

 

 

8.

 

Nature of works

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial Device Installation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Replace Existing Device

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Mailing Address

street

 

 

 

 

 

 

 

 

 

 

 

 

8a.

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Existing Service

 

 

 

 

 

City

 

 

 

 

state

 

 

 

 

 

 

zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8b.

 

 

 

 

New Building

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner's Signature

 

 

 

 

 

 

 

Date

_____/_____/_____

 

 

 

 

 

 

 

 

 

 

Existing Building

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

D

Y

 

 

 

 

 

 

 

 

Major Renovations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Name of Design Engineer or Architect

 

 

 

 

 

 

 

 

 

 

 

10.

 

NYS License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

PE

 

 

RA

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10a.

Telephone Number(s)

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Original Ink signature and seal required on all copies

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

_____/_____/_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

D

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Water System Pressure (psi) at Point of Connection

 

 

12.

Estimate Installation Cost

 

12a.

Estimate Design Cost

 

 

 

 

 

Max ________

Avg ________ Min ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Degree of Hazard

 

 

 

 

 

 

List of processes or reasons that lead to degree of hazard checked:

 

 

 

 

 

Hazardous

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aesthetically Objectionable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Public water supply name

 

 

 

 

 

 

Name of supplier's designate representative

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________

 

 

_____________________________________________________

 

 

street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________________________________

 

 

Signature _________________________

_____/_____/_____

 

 

City

 

state

 

zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

D

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No. (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: All applicants must be accompanied by plans, specifications and an engineer's report describing the project in detail. The project must first be submitted to the water supplier, who will forward it to the local public health engineer. This form must be prepared in quadruplicate with four copies of all plans, specifications and descriptive literature.

DOH-347 (5/91)