Form LW401E "Application for Liquid Waste Permit or Registration" - New Mexico

What Is Form LW401E?

This is a legal form that was released by the New Mexico Environment Department - a government authority operating within New Mexico. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the New Mexico Environment Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LW401E by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW401E "Application for Liquid Waste Permit or Registration" - New Mexico

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New Mexico Environment Department
Application for Liquid Waste Permit or
Environmental Health Bureau
Registration
Liquid Waste Program
☐ Register
☐ Amendment
☐ Conventional
☐ Modify Treatment Unit
☐ Modify Disposal Field
☐ ATS/ADS
☐ Variance
☐ Commercial
Liquid Waste Processing Number:
Section 1 General Information (Incomplete applications will be returned without action)
Field Office ID:
Application Date:
Name (Property Legal owner, Inc., LLC, partnership, DBA, full legal name):
E-mail address(es):
Phone:
Facility Commercial or Institutional Name:
System Location
Mailing Address (Invoices, permits, official correspondence):
: Physical Address, - (if needed, attach directions)
City:
State:
Zip Code:
City:
State:
Zip Code:
NM
Uniform Property Code:
Date of Record:
Lot Size (0.01 acres):
Total No. LW Systems on Property:
Total Design Flow on Property:
Subdivision:
Subdivision Plat Date:
Unit/Phase:
Block
Lot/Tract
Township
Range
Section
.(505)827-6120
No. Connections:
OSE Well Permit No
Private Water Well Location (long., lat. or physical address, city, state):
Water Supply Source:
https://www.ose.state.nm.us/WRAB/index.php
☐ Onsite
☐Private
☐ Offsite
☐Public
Irrigation well, flood irrigation area on lot?
Will a petition for variance be submitted
Public Water System Name:
Enter all LW permit numbers for this lot:
☐ YES
NO ☐
with this application?
☐ Storage
☐ Shared
☐ YES
NO ☐
Section 2 Installer Information
(NMED verifies all licensing information with CID and company registration with the Secretary of State’s Office)
Qualifying Party Name:
Phone:
Licensed Company Name:
(as on file with CID)
☐Corp., Inc.
☐ LLC
Mailing Address (street / PO Box, City, State, Zip):
E-mail address:
☐ Sole Prop.
CID License Classification:
CID Company License No.:
☐LP, LLP
Homeowner
☐MM-1
☐MM-98
☐MS-1
☐MS-3
I am the qualifying party for a licensed company by the State of New Mexico Regulation Licensing Department, Construction Industries Division (CID). I will either personally install the work
myself or authorize company employee(s), ______________________________________________________________________________________________________________
(named here) to provide the services and labor for this permit application under my direct supervision.
Section 3 Authentication / Verification
By signing below, I attest that the information in this application is correct and true to the best of my knowledge. I understand the issuing of this permit does not relieve me from the
responsibility of complying with all applicable provisions of the New Mexico Plumbing Code and the New Mexico Liquid Waste Disposal and Treatment Regulations. Obtaining this permit
does not relieve me from the responsibility of obtaining any permit required by state, city or county regulation or ordinance or other requirements of state or federal law.
Printed Name:
Signature:
Date Signed:
Page 2 must be
☐ Qualifying Party
attached for each
☐ Authorized Rep.
proposed system
☐ Homeowner
on lot
NMED PERMIT TO CONSTRUCT
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Construct No.
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
NMED LIQUID WASTE FEES (permits to construct and operate are valid only upon all fees are being paid), (Amendments no fee required)
☐ Conventional-1000gpd $225
☐ 1001-2000gpd $325
☐ 2001-5000gpd $425
☐ Holding Tank Annual Renewal ($30)
☐ Variance small system $100
☐ ATS/ADS -1000gpd $450
☐ 1001-2000gpd $550
☐ 2001-5000gpd $650
☐ ATS /ADS Annual Renewal ($50)
☐ Variance large system $400
Total Fee Paid
Date Paid
Payment Received By
FINAL INSPECTION OF LW SYSTEM (902I, an approved final inspection report is valid for 180 days as a property transfer evaluation)
Final Inspection Date:
NMED Inspector Name Printed:
☐Installation Approved
☐ Final Inspection
Conducted by NMED
☐Installation Approved with Conditions
Photo inspection date:
Date photos and Completed Form Received by NMED:
(see inspection form for conditions)
☐Contractor photo
☐Installation Not Approved
inspection authorized:
NMED PERMIT TO OPERATE (permits to operate holding tanks and ATS / ADS are only valid for one-year, annual renewals applications required)
A permit for operation of the Liquid Waste system described herein is hereby:
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Operate No.:
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
Form LW 401E 200701
New Mexico Environment Department
Application for Liquid Waste Permit or
Environmental Health Bureau
Registration
Liquid Waste Program
☐ Register
☐ Amendment
☐ Conventional
☐ Modify Treatment Unit
☐ Modify Disposal Field
☐ ATS/ADS
☐ Variance
☐ Commercial
Liquid Waste Processing Number:
Section 1 General Information (Incomplete applications will be returned without action)
Field Office ID:
Application Date:
Name (Property Legal owner, Inc., LLC, partnership, DBA, full legal name):
E-mail address(es):
Phone:
Facility Commercial or Institutional Name:
System Location
Mailing Address (Invoices, permits, official correspondence):
: Physical Address, - (if needed, attach directions)
City:
State:
Zip Code:
City:
State:
Zip Code:
NM
Uniform Property Code:
Date of Record:
Lot Size (0.01 acres):
Total No. LW Systems on Property:
Total Design Flow on Property:
Subdivision:
Subdivision Plat Date:
Unit/Phase:
Block
Lot/Tract
Township
Range
Section
.(505)827-6120
No. Connections:
OSE Well Permit No
Private Water Well Location (long., lat. or physical address, city, state):
Water Supply Source:
https://www.ose.state.nm.us/WRAB/index.php
☐ Onsite
☐Private
☐ Offsite
☐Public
Irrigation well, flood irrigation area on lot?
Will a petition for variance be submitted
Public Water System Name:
Enter all LW permit numbers for this lot:
☐ YES
NO ☐
with this application?
☐ Storage
☐ Shared
☐ YES
NO ☐
Section 2 Installer Information
(NMED verifies all licensing information with CID and company registration with the Secretary of State’s Office)
Qualifying Party Name:
Phone:
Licensed Company Name:
(as on file with CID)
☐Corp., Inc.
☐ LLC
Mailing Address (street / PO Box, City, State, Zip):
E-mail address:
☐ Sole Prop.
CID License Classification:
CID Company License No.:
☐LP, LLP
Homeowner
☐MM-1
☐MM-98
☐MS-1
☐MS-3
I am the qualifying party for a licensed company by the State of New Mexico Regulation Licensing Department, Construction Industries Division (CID). I will either personally install the work
myself or authorize company employee(s), ______________________________________________________________________________________________________________
(named here) to provide the services and labor for this permit application under my direct supervision.
Section 3 Authentication / Verification
By signing below, I attest that the information in this application is correct and true to the best of my knowledge. I understand the issuing of this permit does not relieve me from the
responsibility of complying with all applicable provisions of the New Mexico Plumbing Code and the New Mexico Liquid Waste Disposal and Treatment Regulations. Obtaining this permit
does not relieve me from the responsibility of obtaining any permit required by state, city or county regulation or ordinance or other requirements of state or federal law.
Printed Name:
Signature:
Date Signed:
Page 2 must be
☐ Qualifying Party
attached for each
☐ Authorized Rep.
proposed system
☐ Homeowner
on lot
NMED PERMIT TO CONSTRUCT
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Construct No.
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
NMED LIQUID WASTE FEES (permits to construct and operate are valid only upon all fees are being paid), (Amendments no fee required)
☐ Conventional-1000gpd $225
☐ 1001-2000gpd $325
☐ 2001-5000gpd $425
☐ Holding Tank Annual Renewal ($30)
☐ Variance small system $100
☐ ATS/ADS -1000gpd $450
☐ 1001-2000gpd $550
☐ 2001-5000gpd $650
☐ ATS /ADS Annual Renewal ($50)
☐ Variance large system $400
Total Fee Paid
Date Paid
Payment Received By
FINAL INSPECTION OF LW SYSTEM (902I, an approved final inspection report is valid for 180 days as a property transfer evaluation)
Final Inspection Date:
NMED Inspector Name Printed:
☐Installation Approved
☐ Final Inspection
Conducted by NMED
☐Installation Approved with Conditions
Photo inspection date:
Date photos and Completed Form Received by NMED:
(see inspection form for conditions)
☐Contractor photo
☐Installation Not Approved
inspection authorized:
NMED PERMIT TO OPERATE (permits to operate holding tanks and ATS / ADS are only valid for one-year, annual renewals applications required)
A permit for operation of the Liquid Waste system described herein is hereby:
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Operate No.:
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
Form LW 401E 200701
New Mexico Environment Department
Application for Liquid Waste Permit or
Environmental Health Bureau
Registration
Liquid Waste Program
☐ Amendment
If your lot has more than one LW system, you must fill out a separate application for each system. The site plan drawing must show all liquid waste systems located on your
Liquid Waste Processing Number:
lot. Existing permitted systems must be identified with their LW Permit #. New, modified or unpermitted systems must be clearly labelled on the site plan. NMED agents are
not authorized to amend or complete any portion of this application.
Treatment & Disposal System Design
Section 1 Design Flow, Hydrology, and Soil Description
A. Wastewater Sources & Design Flow Calculations
B. Hydrology Data (depth to limiting layers)
C. Soil Description:
AR=
(Q)
Depth from ground surface to:
Feet
Type
Facility
Flow,
Units (enter number)
gpd
Bedrooms:
Flow:
☐Type Ia: Coarse Sand
☐Single Family Residence A
Seasonal high-water table
1.25
(or up to 30% gravel)
2.0
Bedrooms:
Flow:
☐Type Ib: Medium Sand,
☐Single Family Residence B
Bedrock
Loamy Sand
Bedrooms
Bedrooms
Bedrooms
Bedrooms
Flow:
☐Multiple Family Units
Caliche
(4 or less units, apartments)
Flow:
☐Type II: Sandy Loam,
☐Cluster System:
Clay soils, tight clay
2.0
(description)
Fine Sand, Loam
Multiple Family Units
Method of Design Flow Calculation:
Flow:
Gravel, cobbles, highly permeable soil,
☐ Table 201.1
greater than 30% gravel
(5 or more units, apartments)
☐Type III: Silt, Silt Loam,
☐ PE (Calc. Sheet) Attached
☐Commercial / Institution:
2.0
Test Hole / Soil Borings Used:
Clay Loam, Silty Clay Loam,
☐ YES NO ☐
☐Water Meter Data Attached
Sandy Clay Loam
Flow:
Soil Classification Methodology used:
☐ Jar Test
☐ Calc. Sheet Attached
☐Other
☐ Web Soil Survey
☐ Hand Sampling
(type):
Total Flow:
☐ Laboratory:
Total Flow for
Q=
☐Type IV: Sandy Clay,
☐Sieve
5.0
this LW System:
☐ Other Methodology:
Silty Clay, Clay
Section 2. Treatment Unit and Pump Design:
(Note: 202D, E & F, tank modification or registration requires pumping, and be within one tank size)
No. Septic
Manufacturer:
Series / Model / Certification No.:
Capacity (gallons)
Cover Depth:
Tank(s)
Primary Treatment Unit
☐Septic Tank(s)
(Tanks are approved for max 3’ cover unless
Tank Bedded in:
Pea
Tank Back Fill:
Undisturbed Soil
Compact Soil
Sand
Native soil with no rocks
Pea Gravel
Sand
(circle one)
Gravel
(circle one)
otherwise approved / marked)
Manufacturer:
Series / Model:
Capacity (gallons)
Cover Depth:
☐Pump Tank
☐Pump Basin
Manufacturer:
Series / Model:
Pump Curve Attch’d:
Effluent Pump:
☐Pump
☐YES NO☐
YES NO
☐Dual Pump
Manufacturer:
Series / Model:
Capacity (gallons)
Cover Depth:
☐Standard
☐Secondary
☐Required
☐Conditional
☐Voluntary
☐Tertiary
☐Experimental
Manufacturer:
Series / Model:
All Tank Burial Instructions Attached. Applicant has read and
☐UV
☐Required
understands proper burial instructions & will adhere:
☐Ozone
Disinfection
☐YES NO☐ Initial Here:
☐Voluntary
☐Chlorine
Section 3 Disposal System Design, Components and Calculations:
(Note: 202D&E, disposal field modification requires tank pumping, addition of filter and risers, I/O baffle or T’s checked)
+
A. Minimum Required absorption area, calculated
Min. Sq. Ft. Required:
Existing Sq. Ft. utilized:
Proposed Sq. Ft.:
Total Disposal Area Sq.Ft.
X
=
=
Q
AR
(Multiply Design Flow (Q) times Application Rate (AR):
☐ Other:
B. Design Components:
☐Distribution Box
☐ Drop Box
☐Alternating Drainfield Valve
☐Tee
Trench Width:
Depth Gravel Below Pipe:
Total Linear Feet:
No. of Trenches:
Max Trench Depth:
Length, each trench:
Trench Spacing (ft):
Proposed Sq. Ft.:
☐Pipe & Gravel
☐Elevated
Mfr. Model No &
Sizing Credit (sf/lf, or unit):
Total Linear Feet:
No. of Units:
Max Trench Depth:
Length, each trench:
Trench Spacing (ft):
Proposed Sq. Ft.:
☐Chamber
☐Synthetic Aggregate.
☐Elevated System
☐Seepage Pit
Dimensions (L x W):
Depth below invert:
Proposed Sq. Ft.:
Max Depth:
☐Absorption Bed
☐ET Bed
(fine to med Sand ASTM Specs Attached?)
(unlined, gravity fed)
☐ YES NO ☐
☐Elevated System
No. of Tank(s)
Cover Depth:
High Water Alarm at 80%?
Manufacturer:
NM Certification No.:
Capacity:
☐Holding Tank
☐ YES NO ☐ Set at:__________”
☐Other (description):
☐Privy (outhouse)
☐Split Flow:
☐Vault
(complete holding tank section & septic tank & conventional disposal
section):
Section 4 Alternative Disposal System (ADS) Design, Components and Calculations
For all ADS’s – calculation sheets & site plan drawings (plan view with cross section views) must be submitted with this permit application.
☐Sand-Lined Trench
☐Bottomless Sand Filters
☐Wisconsin Mound
☐Unlined ET Bed
☐Effluent Irrigation Re-use
(804 reduced setbacks allowed)
Sand ASTM Specs Attached?
Sand ASTM Specs Attached?
☐ YES NO ☐
☐Drip Irrigation
☐ YES NO ☐
☐LPD
☐LPP
☐Wetland
☐Graywater
☐Other (description of above system):
Liner Material & Thickness (mils):
Dimensions (L x W) & sq. ft.:
Liner Material & Thickness (mils):
Dimensions (L x W) & sq. ft.:
☐Lined ET Bed
☐Lined Lagoon
(fine to med Sand ASTM Specs Attached?)
(DP Transfers / Registrations Only)
☐ YES NO ☐
☐Other (description, liner specs attached):
1. Does proposed system meet all setbacks required per Table 302.1?
☐ YES NO ☐
Section 5 Setbacks,
2. Site plan attached which shows all structures, LW systems, and wells / waters within 200’, with all setbacks clearly shown?
☐ YES NO ☐
Site Plan & Attachments
3. If ATS or ADS, all requirements under section 403 are submitted, including calculations and drawings?
☐ N/A ☐ YES NO ☐
(check those that apply)
or
or
Supporting Documents Included:
☐Tax Bill
☐Warranty Deed
☐Plat
☐Floorplan
☐Other:
☐Survey
Form LW 401E 200701

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