Form LW401JK "Unpermitted System Inspection Request & Evaluation Report" - New Mexico

What Is Form LW401JK?

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 LW401JK by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW401JK "Unpermitted System Inspection Request & Evaluation Report" - New Mexico

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New Mexico Environment Department
Unpermitted System Inspection Request
& Evaluation Report
Environmental Health Bureau
Liquid Waste Program
GENERAL INFORMATION
(To be completed by Owner or Owner’s Representative)
Name:
e-mail:
Street Address:
CURRENT
OWNER
Phone:
Cell phone:
City, State, Zip:
INFORMATION
Uniform Property Code:
Lot Size:
Site Address:
(to 0.01 Acres)
(13 digit, #-###-###-###-###)
PROPERTY
INFORMATION
Township:
Range:
Section:
Subdivision:
Lot(s):
Tract(s)
Block/Unit:
You must Choose One of the Following or This Application will
When was your system initially installed? (you must circle one)
be “INCOMPLETE”
Before 2/1/02
On or After 2/1/02
(older system)
(newer system)
INITIAL INSTALLATION
Date of system initial installation:
Attached verification of this date:
Verification document type description:
DATE OF SYSTEM
YES
NO
Lot size less than 0.75 acres or design flow
If “Yes” you must submit Verification of Date of Initial Installation when you
loading greater than 500 gpd/acre? (circle one)
submit your application for registration or permit. If you do not submit this
LOT SIZE & DESIGN
FLOW LOADING
information, your application will be considered “INCOMPLETE” and may be
YES
NO
denied.
Current Number of Bedrooms in Residence:
How many bedrooms were present
Commercial/Non-Residential Uses?
If Yes, Describe
when the initial system was installed?
BEDROOMS or DESIGN
FLOW
1
2
3
4
5
6 Other:
N/A
1
2
3
4
5
6
Other:
YES
NO
Water Source (Circle One)
Well on property?
Well Permit #:
Private Well
Public Water
Shared Well
YES
NO
WATER SOURCE
NOTE: If well water is your drinking water source AND your lot size does not meet the minimum lot size requirements at the time
of initial installation, you will need to have your well tested for nitrate and submit the results as part of your application.
Any other sources of wastewater on this property?
If YES, What Permit Numbers?
Describe Other Sources
:
(type and design flow)
OTHER SOURCES OF
WASTEWATER
YES
NO
Have modifications or repairs been made
Date of modification:
Describe modifications:
MODIFICATIONS TO
since the initial installation?
SYSTEM
YES
NO
NMED CHARGES A FEE OF $250 FOR THE DEPARTMENT TO CONDUCT ANY UNPERMITTED SYSTEM INSPECTION
THE DEPARTMENT MAKES NO ASSURACNE THAT THE SYSTEM WILL BE ACCEPTABLE OR MEET REQUIREMENTS
ANY SYSTEM THAT AN OWNER CANNOT PROVIDE A VALID PERMIT NUMBER FOR OR THE DEPARTMENT CANNOT LOCATE A PERMIT ON
FILE WILL BE CONSIDERED AN UNPERMITTED SYSTEM
NOTICE TO OWNER OR OWNER’s AUTHORIZED REPRESENTATIVE: Inspection reports shall not be construed as a
warranty that the system will function properly because of numerous factors (usage, soil characteristics, previous failures, etc.) which
may affect the proper operation of a septic system.
Your signature below attests that you have read and understand the statements above the detailed information provided is
correct and true to the best of your knowledge.
Owner or Representative Name Title:
Representative e-mail:
Representative Phone:
Representative Name Printed
Signature
Date
:
:
:
(Circle One)
NOTE: Systems installed prior to 2/1/02, must be evaluated by an Installer Specialist or an NMED Inspector.
WHO WILL BE
Systems installed on or after 2/1/02, must be evaluated by an NMED Inspector. If applicant fails to declare
NMED Inspector
EVALUATING THIS
a date of installation, NMED shall conduct the inspection and assign an installation date corresponding to the
SYTEM?
effective date of the most current regulation.
Installer Specialist
Fee Paid:
Date Paid:
Payment Received By
NMED ONLY
LIQUID WASTE FEE
($250)
Name Installer Specialist:
Name Licensed Company:
Phone:
INSTALLER
SPECIALIST
INFORMATION
Date of Certification:
Expiration Date:
Are you currently certified by NMED as an Installer Specialist?
YES
NO
(If NO, you cannot conduct inspection)
Applicant must attach a pemrit application to register the system.
LW401JK-20701
NMED DATE STAMP this page when it is received
Page 1 of 6
New Mexico Environment Department
Unpermitted System Inspection Request
& Evaluation Report
Environmental Health Bureau
Liquid Waste Program
GENERAL INFORMATION
(To be completed by Owner or Owner’s Representative)
Name:
e-mail:
Street Address:
CURRENT
OWNER
Phone:
Cell phone:
City, State, Zip:
INFORMATION
Uniform Property Code:
Lot Size:
Site Address:
(to 0.01 Acres)
(13 digit, #-###-###-###-###)
PROPERTY
INFORMATION
Township:
Range:
Section:
Subdivision:
Lot(s):
Tract(s)
Block/Unit:
You must Choose One of the Following or This Application will
When was your system initially installed? (you must circle one)
be “INCOMPLETE”
Before 2/1/02
On or After 2/1/02
(older system)
(newer system)
INITIAL INSTALLATION
Date of system initial installation:
Attached verification of this date:
Verification document type description:
DATE OF SYSTEM
YES
NO
Lot size less than 0.75 acres or design flow
If “Yes” you must submit Verification of Date of Initial Installation when you
loading greater than 500 gpd/acre? (circle one)
submit your application for registration or permit. If you do not submit this
LOT SIZE & DESIGN
FLOW LOADING
information, your application will be considered “INCOMPLETE” and may be
YES
NO
denied.
Current Number of Bedrooms in Residence:
How many bedrooms were present
Commercial/Non-Residential Uses?
If Yes, Describe
when the initial system was installed?
BEDROOMS or DESIGN
FLOW
1
2
3
4
5
6 Other:
N/A
1
2
3
4
5
6
Other:
YES
NO
Water Source (Circle One)
Well on property?
Well Permit #:
Private Well
Public Water
Shared Well
YES
NO
WATER SOURCE
NOTE: If well water is your drinking water source AND your lot size does not meet the minimum lot size requirements at the time
of initial installation, you will need to have your well tested for nitrate and submit the results as part of your application.
Any other sources of wastewater on this property?
If YES, What Permit Numbers?
Describe Other Sources
:
(type and design flow)
OTHER SOURCES OF
WASTEWATER
YES
NO
Have modifications or repairs been made
Date of modification:
Describe modifications:
MODIFICATIONS TO
since the initial installation?
SYSTEM
YES
NO
NMED CHARGES A FEE OF $250 FOR THE DEPARTMENT TO CONDUCT ANY UNPERMITTED SYSTEM INSPECTION
THE DEPARTMENT MAKES NO ASSURACNE THAT THE SYSTEM WILL BE ACCEPTABLE OR MEET REQUIREMENTS
ANY SYSTEM THAT AN OWNER CANNOT PROVIDE A VALID PERMIT NUMBER FOR OR THE DEPARTMENT CANNOT LOCATE A PERMIT ON
FILE WILL BE CONSIDERED AN UNPERMITTED SYSTEM
NOTICE TO OWNER OR OWNER’s AUTHORIZED REPRESENTATIVE: Inspection reports shall not be construed as a
warranty that the system will function properly because of numerous factors (usage, soil characteristics, previous failures, etc.) which
may affect the proper operation of a septic system.
Your signature below attests that you have read and understand the statements above the detailed information provided is
correct and true to the best of your knowledge.
Owner or Representative Name Title:
Representative e-mail:
Representative Phone:
Representative Name Printed
Signature
Date
:
:
:
(Circle One)
NOTE: Systems installed prior to 2/1/02, must be evaluated by an Installer Specialist or an NMED Inspector.
WHO WILL BE
Systems installed on or after 2/1/02, must be evaluated by an NMED Inspector. If applicant fails to declare
NMED Inspector
EVALUATING THIS
a date of installation, NMED shall conduct the inspection and assign an installation date corresponding to the
SYTEM?
effective date of the most current regulation.
Installer Specialist
Fee Paid:
Date Paid:
Payment Received By
NMED ONLY
LIQUID WASTE FEE
($250)
Name Installer Specialist:
Name Licensed Company:
Phone:
INSTALLER
SPECIALIST
INFORMATION
Date of Certification:
Expiration Date:
Are you currently certified by NMED as an Installer Specialist?
YES
NO
(If NO, you cannot conduct inspection)
Applicant must attach a pemrit application to register the system.
LW401JK-20701
NMED DATE STAMP this page when it is received
Page 1 of 6
Unpermitted System Inspection Request
New Mexico Environment Department
Environmental Health Bureau
& Evaluation Report
Liquid Waste Program
GENERAL INFORMATION
Owner Name:
Mailing Address:
City, State, Zip:
e-mail:
Phone:
Cell phone:
Date of Record:
Date of Installation:
System Location Address:
LW Permit No.
UNPERMITTED LIQUID WASTE SYSTEM INSPECTION
To be completed by Installer Specialist or NMED Inspector
Phone:
Approval Date:
SEPTAGE PUMPER INFORMATION
Name of Company:
Name Septage Pumper:
Qualified Septage Pumper:
SEPTAGE PUMPER INFO
YES
NO
Unpermitted Septic Tank
Latitude
:
Longitude
:
Elevation
:
(DD.ddddd°)
(DDD.ddddd°)
(Feet)
LOCATION
Size (gallons):
Material:
Manufacturer of Tank:
1000 1200 1500 Other:
Concrete
Plastic
Fiberglass
Other
SIZE
Note:
&
Tank Cover Depth
Covers Secure?
Describe: (58#, screw, twist, hasp):
Year Tank Manufactured:
(Top of Tank to
MATERIALS
grade) (3’ max unless otherwise approved):
(as marked on tank)
YES
NO
Structural Cracking
Excessive Deterioration
Rust Streaks
Exposed Aggregate
Exposed Rebar/Wire
Tank/Manhole Deformed
VISIBLE DESCRIPTORS
Notes:
(Circle All that Apply)
Inlet Sewer line, size, material, rating
Inlet pipe slope:
Outlet line, size, material, rating
Outlet pipe slope:
PIPES
Access Risers - Inlet & Outlet?
Covers Secure?
Describe Secure: (58#, screw, twist, hasp)
Riser, watertight attached to
)
tank?
(Req’d 1997 1 ft. grade, 2005 to grade
YES
NO
Not Required
YES
NO
YES
NO
RISERS
Effluent Filter (2005) Handle (2013) w/in
Number of Risers on
Riser Internal Diameter:
Material: (describe)
6” cover
tank:
Measured:___________”
YES
NO
Not Required
0
1
2
Gallons pumped from tank:
Tank Water Level at Outlet
Tank Level?
(Circle One)
(Circle One)
Above
YES
NO
At Invert
Invert
Below Invert
FUNCTIONALITY
Inlet Tee or Baffle
Outlet Tee or Baffle
Baffle Wall
(Circle One)
(Circle One)
(Circle One)
OK
NOT OK
OK
NOT OK
OK
NOT OK
Setbacks to On-site Water Well (50 ft)
Setbacks to Neighbor’s Well (50 ft)
Setbacks to Public Water Well (100 ft)
SEPTIC
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
TANK
Distance:
Distance:
Distance:
(feet)
(feet)
(feet)
SETBACKS
Setbacks: (
To Property Lines, Structures, Waterlines
Setbacks to Disposal System
State Waters, Arroyos, Ditches)
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
High Level Alarm Set at 80% and
Alarm set water depth: (inches)
Water tightness
Pumping Records Available?
HOLDING
working properly?
Test:
TANK
YES
NO
N/A
Pass
Fail
YES
NO
N/A
Comments, Note any Problems, or Concerns:
LW401JK-20701
NMED DATE STAMP this page when it is received
Page 2 of 6
LW Permit No.
LIQUID WASTE UNPERMITTED SYSTEM INSPECTION
To be completed by Installer Specialist or NMED Inspector
Owner Name:
System Location:
Unpermitted Disposal System
Trench
Pipe and Gravel
Chambers
Synthetic Aggregate
Other
Seepage Pit
Absorption Bed
Elevated System with Lift Station
UNABLE TO VERIFY
Conventional
Dimensions, slope, spacing (req’d newer systems):
Elevated System with Pressure-Dosing
Wisconsin Mound
ET Bed
Gray Water System Drip System
Low-pressure Dosed
Split-Flow
Bottomless Sand Filter
Sand-lined Trench
Soil-Replacement
Alternative/
Vault
Privy
Constructed Wetlands
Other:
UNABLE TO VERIFY
Other
Dimensions, slope, spacing (req’d newer systems):
Did you Probe
Approximately how many Gallons of
Method used to determine gallons added.
(Bucket
measurement, water meter, assumed gpm, show calculation)
Disposal Field Area?
water added for Water Test?
YES
NO
Gallons Added: _____________
☐Type III: Silt, Silt Loam, Clay
Any Indication
Seepage Visible
Lush
Soil Type: (required for newer systems)
☐Type Ia: Coarse Sand
of Previous
on Lawn?
Vegetation
Loam, Silty Clay Loam, Sandy
(or up to 30% gravel)
☐Type Ib: Medium Sand, Loamy Sand
Failure?
Present?
Clay Loam
☐Type IV: Sandy Clay, Silty
☐Type II: Sandy Loam, Fine Sand, Loam
YES
NO
YES
NO
YES
NO
Clay, Clay
How did you determine soil type? (please describe)
Setbacks to On-site Water Well (100 ft)
Setbacks to Neighbor’s Well (100 ft)
Setbacks to Public Water Well (200 ft)
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
Distance: _______________Feet
Distance: _______________Feet
Distance: _______________Feet
Setbacks: State Waters, Arroyos, Ditches
To Property Lines, Structures, Waterlines
Setbacks to Septic Tank
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify N/A
Met Not Met Unable to Verify
Does System appear to meet the minimum clearance requirements to limiting layers? (groundwater, bedrock, clay, etc)
CLEARANCE
Met
Not Met
Unable to Verify
FUNCTIONALITY
Does the Disposal System Appear to be Functioning Properly?
YES
NO
Comments, Note any Problems, or Concerns:
SKETCH DISPOSAL SYSTEM PLAN VIEW AND PROFILE VIEW
LW401JK-20701
NMED DATE STAMP this page when it is received
Page 3 of 6
LW Permit No.
LIQUID WASTE UNPERMITTED SYSTEM INSPECTION
To be completed by Installer Specialist or NMED Inspector
:
System Location:
Owner Name
Unpermitted Pump Tanks & Alarm Systems
[ ]Not Applicable
check here if not applicable
Latitude
Longitude
Elevation
(DD.ddddd°):
(DDD.ddddd°):
(Feet):
LOCATION
Size (gallons):
Material:
Manufacturer of Tank:
1000 1200 1500 Other:
Concrete
Plastic
Fiberglass
Other
Note:
Tank Cover Depth
Covers Secure?
Describe: (58#, screw, twist, hasp)
Year Tank Manufactured
(Top of Tank to grade)
(as marked on tank):
(3’ max unless otherwise approved)
YES
NO
Does tank appear to be watertight?
Tank Water Level
:
Gallons pumped:
(as measured)
Tank Level?
(Circle One)
YES
NO
YES
NO
Structural Cracking
Excessive Deterioration
Rust Streaks
Exposed Aggregate
Exposed Rebar/Wire
Tank/Manhole
VISIBLE DESCRIPTORS
Deformed
(Circle All that Apply)
Notes:
Riser, watertight attached to tank?
Access Risers - Inlet & Outlet?
Covers Secure?
Describe Secure:
(58#, screw, twist, hasp)
)
(Req’d 1997 1 ft. grade, 2005 to grade
YES
NO
Not Required
YES
NO
YES
NO
Material: (describe)
Riser Internal Diameter:
Type of Pump:
Is pump operating properly?
(24”,
Single
Dual Alternating
30”)
Measured:___________”
YES
NO
High Level Alarm Works?
Floats secure
Alarm and Pump on Separate circuits?
Alarm / Breaker
Pump / Breaker
Main Breaker Amps:
ALARM
Amps:
Amps:
YES
NO
YES
NO
YES
NO
Setbacks to On-site Water Well (50 ft)
Setbacks to Neighbor’s
Setbacks to Public Water
Well (50 ft)
Well (100 ft)
Met Not Met Unable to Verify N/A
Met Not Met Unable to
Met
Not Met
Unable to
Verify N/A
Verify N/A
Distance:
Distance:
Distance:
(feet)
(feet)
(feet)
Setbacks: (
To Property Lines, Structures, Waterlines
Setbacks to Disposal
State Waters, Arroyos, Ditches)
System
Met Not Met Unable to Verify N/A
Met Not Met Unable to
N/A
Met Not Met Unable to
Verify
Verify N/A
Comments, Note any Problems, or Concerns:
Are you a Qualified MSP?
Unpermitted Advanced Treatment Systems can only be evaluated by a Qualified Maintenance
Service Provider.
YES
NO
Name of Manufacturer:
Model/Capacity:
What Level of Treatment:
TYPE OF ATS
Secondary
Tertiary Disinfection
Aerator is working
System appears to have been
Name of person maintaining this system?
properly?
properly maintained?
FUNCTIONALITY
YES
NO
YES
NO
Is there an active Maintenance &
Has a Maintenance & Monitoring event
Are Results of Maintenance & Monitoring
Monitoring Contract currently in effect?
occurred within last 180 days?
Report Attached?
MAINTENANCE
DON’T
YES
NO
YES
NO
YES
NO
KNOW
Model approval level TN:
Max TN calculated for lot size:
Latest TN:
Previous TN
Unit meets performance requirement:
MONITORING
RESULTS
(for secondary units
YES
NO
enter BOD/TSS values)
Note any problems, concerns or comments:
LW401JK-20701
NMED DATE STAMP this page when it is received
Page 4 of 6
LW Permit No.
LIQUID WASTE UNPERMITTED SYSTEM INSPECTION
To be completed by Installer Specialist or NMED Inspector
Owner Name:
System Location:
Draw a Simple Sketch of the System (Location of House, Property Lines, System Components and Location of On-site and Neighboring
Wells. Also include Setback distance from House to Septic Tank. For systems which were installed on or after 2/1/02 you must also
include the soil type & disposal field material, sizing & spacing on this sketch)
LW401JK-20701
NMED DATE STAMP this page when it is received
Page 5 of 6

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