Doh 5025 Form PDF Details

The Doh 5025 form is an essential document managed by the New York State Department of Health Bureau of Water Supply Protection (NYSDOH BWSP). It functions as an Engineer's Certification of Public Water Improvement Project Completion, playing a crucial role in the development and maintenance of public water systems. The form requires detailed information, including the public water system name, PWISD number, and project location, demanding precise data regarding the drinking water State Revolving Fund (DWSRF) project status, whether plans have received necessary approvals from NYSDOH BWSP or other authorities such as NYSDOH regional or district offices or the county health department. Furthermore, it outlines critical timelines, describing the construction start and substantial completion dates, supplemented by a comprehensive project description. An important aspect of the form involves the certification by the submitting engineer, declaring that the project complies with approved plans, specifications, and any required environmental mitigating measures. It also mandates the submission of "as-built" record drawings and operational manuals to the project owner. Additionally, any deviations from the original plans must be clearly documented and attached. The form's completion and submission depend on whether the NYSDOH BWSP has initially approved the project plans, with specific instructions for submitting the finalized document to either NYSDOH BWSP's main office or the relevant regional, district office, or county health department, signifying the form's pivotal role in ensuring the safety and compliance of public water improvement projects within New York State.

QuestionAnswer
Form NameDoh 5025 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesny completion sample, nysdoh bwsp, doh 3735 form 2019, doh 5025 pdf

Form Preview Example

New York State DepartmeNt of HealtH Bureau of water Supply protection

Engineer’s Certification of Public Water Improvement Project Completion

New York State Department of Health Bureau of Water Supply Protection (NYSDOH BWSP)

Application for an Approval of Completed Works

1. public water System Name:

 

 

 

 

 

2. pwSID Number:

 

3. project location

 

 

(City, town, Village)

 

 

 

 

 

County

 

4. Drinking water State revolving fund (DwSrf) project:

Yes

No

If Yes, DwSrf project Number:

 

 

 

 

 

 

 

 

 

 

 

 

5. plans approved by NYSDoH BwSp:

Yes

No

If Yes, NYSDoH BwSp project log Number:

 

 

 

 

plans approved by : (check all that apply)

 

 

 

 

 

 

 

 

 

 

 

NYSDoH regional office

NYSDoH District office

County Health Department

6. Construction Start Date:

 

 

 

7. Substantial Construction Completion Date:

 

 

 

 

 

 

 

 

 

 

 

 

(provide a copy of the notice to proceed with this application)

8. project Description:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.pursuant to the NYS Sanitary Code part 5, Subpart 5-1, Section 5-1.22 I hereby request that an approval of Completed works be issued for the above referenced project. By affixing my seal and signature to this document I certify that the construction of the referenced project including any required environmental mitigating measures was substantially completed in accordance with the approved plans and specifications or approved amendments thereto. In addition,

a set of the final “as-Built” record drawings and operation and equipment manuals, have been, or will be, provided to the project owner.

10.Deviations from approved plans:

(attach separate sheets if additional space is needed)

11. engineering firm:

(Name of firm)

(print Contact person Name)

 

(phone Number)

NYSEngineersSealandSignature

Date Signed:

If the box for he NYSDOH BWSP is checked Yes in item 5:

Send completed form to: NYSDoH BwSp empire State plaza Corning tower, room 1168 albany, NY 12237

or e-mail to: bpwsp@health.state.ny.us

If the box for he NYSDOH BWSP is not checked Yes in item 5, then send the completed form to the appropriate Regional office, District office or the County Health Department that approved the plans.

DoH-5025 (11/12)

How to Edit Doh 5025 Form Online for Free

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With regards to the blanks of this particular PDF, this is what you need to know:

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nysdoh completed sample writing process explained (part 1)

2. The third step is to complete these blank fields: project By affixing my seal and, Deviations from approved plans, engineering firm, Name of firm, attach separate sheets if, phone Number, print Contact person Name, Date Signed, NYS Engineers Seal and Signature, If the box for he NYSDOH BWSP is, Send completed form to, NYSDoH BwSp empire State plaza, or email to, bpwsphealthstatenyus, and If the box for he NYSDOH BWSP is.

If the box for he NYSDOH BWSP is, Deviations from approved plans, and Name of firm of nysdoh completed sample

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