Michael C. Caldwell, MD, MPH, Commissioner
~ Most Requested Forms ~
Application to Access Records - FOIL (.pdf)
Tobacco Sale Registration and Permit Application (.pdf)
Wastewater Disposal System Registration and Notice of Intent (SAN-36) (.pdf)
- For homeowners and installers
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Food Service
Food Establishment Self Inspection Checklist (HD-SAN141) (.pdf)
- For use by food service operators and managers to facilitate compliance with the New York State Sanitary Code, Subpart 14-1.
Temporary Food Service Permit Application (.pdf)
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General Engineering
Application for Approval of Plans for Public Water Supply Improvements (DOH-348) (.pdf)
- For use by engineers/licensed architects, operators
Application for the Approval of Plans and Specifications for Construction of or Alteration to an Artificial Swimming Pool and Appurtenances (Gen-134) (.pdf)
- For use by engineers/licensed architects, operators
Certification of Construction Compliance (HD-159) (.pdf)
- For use by engineers/licensed architects, operators
Engineering Report for Swimming Pool Plans (DOH-1309) (.pdf)
- For use by engineers/licensed architects, operators
Engineer's Certification of Public Water Improvement Project Completion (DOH-5025) (.pdf)
- For use by engineers/licensed architects, operators
Sewer/Water Adequacy for New/Revised Use (HD-ENH300) (.pdf)
- For use by business owners and operators
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Health Care Providers
Confidential Case Report (DOH-389) (.pdf)
- For use by Health Care Providers. Please see the Physician's Guide to Dutchess County Public Health Services Reporting Requirements (.pdf) for further information.
Dutchess County Department of Health Sexually Transmitted Disease Reporting (.pdf)
- For use by Health Care Providers. Please see the Physician's Guide to Dutchess County Public Health Services Reporting Requirements (.pdf) for further information.
Dutchess County Department of Health Suspected Rabid Animal or Rabies Exposure Report (.pdf)
- For use by Health Care Providers to report a contact between a human and a potentially rabid animal. The completed form should be faxed to the Dutchess County Department of Health at (845) 486-3545.
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Subdivision and Individual Lots
Deep Test Results (HD-185) (.pdf)
- For plan approval documentation by engineers/licensed architects
Extension of Approval, Application for (HD-164) (.pdf)
- For use by owners to request extension of expired or expiring approvals.
Fill Section Certification (HD-5) (.pdf)
- For plan approval documentation by engineers/licensed architects
Low Yield Wells Approval Application (WW-2) (.pdf)
- For use by homeowners
Percolation Test Results (HD-184) (.pdf)
- For plan approval documentation by engineers/licensed architects
Plans for a Wastewater Disposal System, Application for Approval of (HD-1) (.pdf)
- For plan approval documentation by engineers/licensed architects
Residential Sewage Disposal System, Application for Approval of (SAN-34) (.pdf)
- For use by building inspectors
Sanitary Facilities for Realty Subdivision, Application for Approval of (HD-157) (.pdf)
- For plan approval documentation by engineers/licensed architects
Waiver Request Form (HD-160) (.pdf)
- For use for waivers from established codes and standards
Wastewater Disposal System Registration and Notice of Intent (SAN-36) (.pdf)
- For homeowners and installers
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Tobacco
Tobacco Sale Registration and Permit Application (.pdf)
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Training Courses
Application for Water or Pool Operator Course (.pdf)
- For use by prospective operators
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Water Supply
Annual Water Quality Report Certification Form (.pdf)
- For use by water operators
Annual Water Quality Report Templates
- For use by water operators
Approval of <5 GPM Well, Application for (WW-2) (.pdf)
- For use by owners
Certificate of Waiver from Asbestos Sampling Requirement, Application for a (DOH-351) (.pdf)
- For use by owners/operators
Certificate of Waiver from Disinfection Requirement, Application for (DCHD-350) (.pdf)
- For use by owners/operators
Consecutive Agreement Information (DOH-CAI) (.pdf)
- For use by owners/operators
Designation of Water Operator in Responsible Charge (DOH-4204) (.pdf)
- For owners/operators
Sample Site Identification and Certification (.pdf)
- For use by owners/operators
Water System Operation Report for Ultra-Violet Disinfection Systems Only (.pdf)
- For use by owners/operators
Water Well, Application to Construct or Abandon (SAN-35) (.pdf)
- For use by well drillers
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Weights and Measures
Precious Metal License Renewal (.pdf)
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Miscellaneous
Application to Access Records - FOIL (.pdf)
Data Request Form (.pdf) - Electronic Submission
- Use the above version to complete the form online and submit it electronically. You must have Adobe Acrobat Standard or Adobe Acrobat Professional installed on your computer to use this version of the form.
Data Request Form (.pdf)
- Use the above version to complete the form online then print it and fax it to the Dutchess County Department of Health at (845) 486-3561. This version can be completed using Adobe Reader only.
Department of Health Website Satisfaction Survey
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Accessibility:
County Executive