Form LW902 "Property Transfer Evaluation Report for Permitted Onsite Liquid Waste Systems" - New Mexico

What Is Form LW902?

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;
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  • Fill out the form in our online filing application.

Download a printable version of Form LW902 by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW902 "Property Transfer Evaluation Report for Permitted Onsite Liquid Waste Systems" - New Mexico

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New Mexico Environment Department
Property Transfer Evaluation Report
Environmental Health Bureau
for Permitted Onsite Liquid Waste Systems
Liquid Waste Program
Liquid Waste Permit Number:
GENERAL INFORMATION
To be completed by Owner or Owner’s Representative
EXISTING
Existing Permit Number(s)
Lot Size on Permit (to 0.01 acres)
Number of Bedrooms on Permit
PERMIT
INFORMATION
CURRENT
Name
Mailing Address
Phone
OWNER
________________________________
INFORMATION
Site Address
Uniform Property Code
Lot Size (to 0.01 Acres)
(13 digits, #-###-###-###-###)
PROPERTY
________________________________________
INFORMATION
Township/Range/Section
Subdivision
Lot/Tract/Block/Unit
RESIDENCE
Current Number of Bedrooms in Main
Other structure on property being
Describe Current Number of
INFORMATION
Residence
used as a residence?
Bedrooms In Other Residential
Structures:
1
2
3
4
5
6 Other:
YES
NO
WATER SOURCE
Water Source (Circle One)
Well on your property?
Well Permit Number
Private Well
Public Water
YES
NO
Shared Well
No. Connections ______________
OTHER
Any other sources of wastewater on this
If YES, What Permit Numbers?
Describe Other Sources
SOURCES OF
property?
WASTEWATER
YES
NO
THIRD PARTY EVALUATOR INFORMATION
To be completed by Third Party Evaluator, Owner or Owner’s Representative
EVALUATOR
Name of Person Evaluating LW System
Name of Company
Phone Number
INFORMATION
THIRD PARTY
MM-98
MM-01
MS-03
MS-01
PE
NSF
License/Certification#
Expiration Date
EVALUATOR
NEHA REHS/RS OTHER (Approved by NMED)
QUALIFICATION
For “OTHER” state date apprvoved by NMED:
Name of Company
Name of Septage Pumper
Is this person a Qualified Septage Pumper
SEPTAGE
under Section 904(D) of Regulations?
PUMPER INFO
YES
NO
OTHER INFORMATION
NOTICE TO OWNER OR AGENT:
1. This report shall not be construed as a warranty that the system will function properly because of the numerous
factors (usage, soil characteristics, previous failures, etc.) which may affect the proper operation of a septic system.
2. A fee or $50.00 will be charged by the department upon filing this report to be included in the official record.
Your signature below attests that the above detailed information is correct and true to the best of your
knowledge.
Owner or Authorized Representative Name Printed
Signature
Date
Form LW 902 200701
Page 1 of 4
NMED DATE STAMP ALL 4 PAGES UPON SUBMITTAL
New Mexico Environment Department
Property Transfer Evaluation Report
Environmental Health Bureau
for Permitted Onsite Liquid Waste Systems
Liquid Waste Program
Liquid Waste Permit Number:
GENERAL INFORMATION
To be completed by Owner or Owner’s Representative
EXISTING
Existing Permit Number(s)
Lot Size on Permit (to 0.01 acres)
Number of Bedrooms on Permit
PERMIT
INFORMATION
CURRENT
Name
Mailing Address
Phone
OWNER
________________________________
INFORMATION
Site Address
Uniform Property Code
Lot Size (to 0.01 Acres)
(13 digits, #-###-###-###-###)
PROPERTY
________________________________________
INFORMATION
Township/Range/Section
Subdivision
Lot/Tract/Block/Unit
RESIDENCE
Current Number of Bedrooms in Main
Other structure on property being
Describe Current Number of
INFORMATION
Residence
used as a residence?
Bedrooms In Other Residential
Structures:
1
2
3
4
5
6 Other:
YES
NO
WATER SOURCE
Water Source (Circle One)
Well on your property?
Well Permit Number
Private Well
Public Water
YES
NO
Shared Well
No. Connections ______________
OTHER
Any other sources of wastewater on this
If YES, What Permit Numbers?
Describe Other Sources
SOURCES OF
property?
WASTEWATER
YES
NO
THIRD PARTY EVALUATOR INFORMATION
To be completed by Third Party Evaluator, Owner or Owner’s Representative
EVALUATOR
Name of Person Evaluating LW System
Name of Company
Phone Number
INFORMATION
THIRD PARTY
MM-98
MM-01
MS-03
MS-01
PE
NSF
License/Certification#
Expiration Date
EVALUATOR
NEHA REHS/RS OTHER (Approved by NMED)
QUALIFICATION
For “OTHER” state date apprvoved by NMED:
Name of Company
Name of Septage Pumper
Is this person a Qualified Septage Pumper
SEPTAGE
under Section 904(D) of Regulations?
PUMPER INFO
YES
NO
OTHER INFORMATION
NOTICE TO OWNER OR AGENT:
1. This report shall not be construed as a warranty that the system will function properly because of the numerous
factors (usage, soil characteristics, previous failures, etc.) which may affect the proper operation of a septic system.
2. A fee or $50.00 will be charged by the department upon filing this report to be included in the official record.
Your signature below attests that the above detailed information is correct and true to the best of your
knowledge.
Owner or Authorized Representative Name Printed
Signature
Date
Form LW 902 200701
Page 1 of 4
NMED DATE STAMP ALL 4 PAGES UPON SUBMITTAL
Liquid Waste Permit Number:
LIQUID WASTE SYSTEM EVALUATION
To be completed by Third Party Evaluator
Septic Tank
LOCATION
Latitude
Longitude
Elevation
(DD.ddddd°)
(DDD.ddddd°)
(Feet)
SIZE and
Size (gallons)
Material
Manufacturer of Tank
MATERIALS
Concrete
Plastic
Fiberglass
1000 1200 1500 Other: ____________
Other Note:
Tank Dimensions:
Covers Secure?
Tank Cover Depth
Year Tank Manufactured
(ext lth x wth x lq dth, inches)
(Top of Tank to grade) (3’
max unless otherwise approved)
(as marked on tank)
___________x______________x__________
YES
NO
____________________________________ feet
ACCESS RISERS
Access Risers - Inlet & Outlet?
Effluent Filter?
Handle on Effluent Filter within 6” cover?
(Required 2005)
)
(Required 2013)
(Req’d 1997 1 ft. grade, 2005 to grade
YES
NO
Not Required
YES
NO
Not Required
YES
NO
Not Required
Number of Risers on tank: (over inlet and
Riser Internal Diameter: (inches)
Material: (metal prohibited)
(3’ cover 24”, over 3’ cover 30” rqr’d)
outlet, over baffle wall vent not acceptable)
Concrete coated
Plastic
0
1
2
24” 30” Other:______
Concrete Type V
FUNCTIONALITY
How many Gallons were pumped for this
Water Level in Tank at Outlet
Does Tank appear Level?(Circle One)
(Circle One)
evaluation?
__________________Gallons
Above Invert
At Invert
Below Invert
YES
NO
Inlet Tee/Baffle (Circle One)
Outlet Tee/Baffle (Circle One)
Baffle Wall (Circle One)
OK
NOT OK
OK
NOT OK
OK
NOT OK
Note:
Note:
Note:
VISIBLE
Structural Cracking
Excessive Deterioration
Rust Streaks
Exposed Aggregate
Exposed Rebar/Wire
Tank/Manhole
DESCRIPTORS
Deformed
(Circle All that Apply)
Notes:
SEPTIC TANK
Setbacks to On-site Water Well (50 ft)
Setbacks to Neighbor’s Well (50 ft)
Setbacks to Public Water Well (100 ft)
SETBACKS
Met Not Met Unable to Confirm N/A
Met Not Met Unable to Confirm N/A
Met Not Met Unable to Confirm N/A
Distance: _______________Feet
Distance: _______________Feet
Distance: _______________Feet
Setbacks: State Waters, Arroyos, Ditches
To Property Lines, Structures, Waterlines
Setbacks to Disposal System
Met Not Met Unable to Confirm N/A
Met Not Met Unable to Confirm N/A
Met Not Met Unable to Confirm N/A
HOLDING
Annual Operating Permit Approved?
High Level Alarm working properly?
Appears to be Watertight?
Pumping Records Available?
TANK
YES
NO
N/A _____________
YES
NO
N/A _______________
YES
NO
N/A
YES
NO
N/A
Note any Problems, Concerns or Comments:
Disposal System
TYPE OF DISPOSAL
Conventional
Trench
Pipe and Gravel
Chambers
Synthetic Aggregate
Other
SYSTEM
Seepage Pit
Leaching Bed
Elevated System with Lift Station
Circle ALL that apply
Alternative/
Elevated System with Pressure-Dosing
Wisconsin Mound
ET Bed
Gray Water System Drip System
Other
Low-pressure Dosed
Split-Flow
Bottomless Sand Filter
Sand-lined Trench
Soil-Replacement
Vault
Privy
Constructed Wetlands
Other:
Annual Operating Permit Approved?
ANNUAL
OPERATING
YES
NO
N/A _____________
PERMIT
DISTRIBUTION BOX
Is there a D-Box on this system?
Watertight & Equal Distribution of Flow?
Access to D-Box? (Required 2013)
YES
NO
UNABLE TO CONFIRM
YES
NO
UNABLE TO CONFIRM
YES
NO
INSPECTION
Did you Probe Disposal Field Area?
Approximately how many Gallons of
Method used to measure gallons?
METHODS &
water added for Hydraulic Water Test?
Bucket 5 gal, minutes:
YES
NO
OBSERVATIONS
Gallons Added: _____________
Water meter:
Approximate:
Any Indication of Previous Failure?
Seepage Visible on Lawn?
Lush Vegetation Present?
YES
NO
YES
NO
YES
NO
Evidence of Ponding Water in Field?
Even Distribution of Effluent in Field?
Any Septic Odor Present?
YES NO N/A
YES
NO N/A
YES
NO
UNABLE TO CONFIRM
UNABLE TO CONFIRM
DISPOSAL SYSTEM
Setbacks to On-site Water Well (100 ft)
Setbacks to Neighbor’s Well (100 ft)
Setbacks to Public Water Well (200 ft)
SETBACKS
Met Not Met Unable to Confirm N/A
Met Not Met Unable to Confirm N/A
Met Not Met Unable to Confirm N/A
Distance: _______________Feet
Distance: _______________Feet
Distance: _______________Feet
Setbacks: State Waters, Arroyos, Ditches
To Property Lines, Structures,
Setbacks to Septic Tank
Met Not Met Unable to Confirm N/A
Waterlines
Met Not Met Unable to Confirm
Met Not Met Unable to Confirm N/A
Form LW 902 200701
Page 2 of 4
NMED DATE STAMP ALL 4 PAGES UPON SUBMITTAL
Liquid Waste Permit Number:
LIQUID WASTE SYSTEM EVALUATION
To be completed by Third Party Evaluator
FUNCTIONALITY
Does the Disposal System Appear to be
If proprietary product, was system installed in accordance with manufacturer’s
Functioning Properly?
specifications and permit design?
YES
NO
N/A
Yes
No
Unable to Confirm
Note any Problems, Concerns or Comments:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Advanced Treatment System
[ ]Not Applicable
check here if not applicable
ATSs can only be evaluated by a Qualified Maintenance Service Provider.
Are you a Qualified MSP?
YES
NO
TYPE OF ATS
Name of Manufacturer
Model/Capacity
What Level of Treatment
Secondary
Tertiary Disinfection
FUNCTIONALITY
Aerator is working
System appears to have
Disinfection unit is working properly?
Has System been meeting treatment
properly?
been properly maintained?
levels required on permit?
Chlorine
UV
Other:__________
YES
NO
YES
NO
YES
NO
DON’T KNOW
YES
NO
N/A
MAINTENANCE
Is there an active Maintenance &
Has a Maintenance & Monitoring event
Are Results of Maintenance &
Monitoring Contract currently in effect?
occurred within last 180 days?
Monitoring Report Attached?
YES
NO
YES
NO
DON’T KNOW
YES
NO
Name of MSP:______________________
Annual Operating Permit Approved?
ANNUAL
Mfr’s Maintenance Checklist Attached:
Level of Treatment Required for:
OPERATING
YES
NO
N/A _____________
YES
NO
Lot size Clearance Setback Soil
PERMIT
Note any Problems, Concerns or Comments:
Pump Systems
[ ]Not Applicable
check here if not applicable
FUNCTIONALITY
Is pump operating properly?
Is pump above Tank floor?
High Level Alarm Works?
YES
NO
YES
NO
YES
NO
Alarms and pumps on separate circuits?
Is pump wiring protected?
Both Audible & Visible Alarms present?
YES
NO
YES
NO
YES
NO
Is there a Riser to Grade w/ Secure Lid?
Is tank watertight and structurally
Is there a Check Valve & Purge/Vent
YES
NO
sound?
Hole?
YES
NO
YES
NO
Note any Problems, Concerns or Comments:
Draw a Simple Sketch of the System (Include North Arrow, Location of House, Property Lines, System Components and Location of On-site and Neighboring Wells.
Also include Setback distance from House to Septic Tank)
Form LW 902 200701
Page 3 of 4
NMED DATE STAMP ALL 4 PAGES UPON SUBMITTAL
Liquid Waste Permit Number:
Property Transfer Evaluation Summary
For Permitted Onsite Liquid Waste Systems
Note: Unlicensed evaluators, septage pumpers, maintenance service providers and any unlicensed entity cannot
repair or modify a liquid waste system
Circle One
Evaluation Criteria
You must circle one for each item or
(pursuant to Section 902(F) and (G) of 20.7.3 NMAC)
this form will be considered incomplete
1
Public Health and
Does this system currently constitute a public health or safety hazard?
NO
YES
1
Safety
2
Septic Tank/
Is the septic tank/treatment unit watertight and functioning properly?
YES
NO
2
Treatment Unit
2
Disposal System
Does the disposal system appear to be functioning properly?
YES
3
NO
2
Setbacks and
Does the system appear to meet all setbacks and clearances to waters?
YES
NO
4
Clearances to waters
3
Setbacks and
Does the system appear to meet all setbacks and clearances to all other than
YES
NO
5
Clearances to all
waters and greater than 1 foot?
other than waters
3
Lot Size
Does the system installed on this property meet the lot size requirement in
YES
NO
6
Requirements
effect at the time of the initial installation, or in effect at the time of the
most recent permitted modification?
3
Bedrooms/Design
Has the number of bedrooms (or design flow) increased from the number of
NO
YES
7
Flow
bedrooms or design flow stated on original permit?
2
Advanced Treatment
Is a Monitoring or Sampling Report attached, which has been completed
YES
NO
8
Systems
within the past 180 days? (Required for All ATSs)
N/A
Liquid waste system appears to be functioning properly
Septic Tank Needs Replacement
Septic Tank Needs Repairs
Evaluator
Disposal System Needs Replacement/Expansion or Repairs
ATS Needs Replacement, Maintenance /Repairs
Recommendations
Comments (describe any problems with the system and any repairs made):
Circle All that Apply
Only licensed contractors and their employees may construct, repair, or replace components of a permitted septic
system, this includes the following activities; install risers, repair risers or broken riser covers, install tee’s, install
filters, repair or replace pumps or aerators, repair leaking tanks, install or repair inspection ports, provide
invoices for said repairs and collect payments for licensed companies only
By signing below, I acknowledge that I personally conducted this evaluation & the information contained in this report is correct and true to the best of my knowledge.
Evaluator’s Name Printed
Evaluator’s Signature
Date
The evaluating company and/or individual evaluator disclaims any warranty, either expressed or implied, arising from the evaluation of the
wastewater system or this report.
For systems that do not meet the evaluation criteria specified above (1, 2 or 3), appropriate action shall be taken by the property
owner to assure that these systems are brought into compliance with The Liquid Waste Regulations 20.7.3 NMAC. See Below
Immediate action is required by property owner to remedy hazard
1
A permit modification, system repairs or permit amendment are required. If permit modification is required, an application must
2
be submitted to NMED Field Office within 15 days of this evaluation. The system must be brought into compliance with current
standards. For ATSs, a current sampling report must be submitted.
No Action is required at this time. When system fails or it is modified, the system must be brought up to the standards of the
3
regulations in effect at the time of system failure or modification. An advanced treatment system may be required.
Fee Paid:
Invoice #
Date Paid:
Payment Received By
NMED ONLY
LIQUID WASTE FEE
($50)
NMED DATE STAMP for Date Received
Return this completed report to the local NMED Field
Office within 15 days of the evaluation.
This form is valid for 180 days after the date the
evaluation was conducted.
Form LW 902 200701
Page 4 of 4
NMED DATE STAMP ALL 4 PAGES UPON SUBMITTAL

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