"Ground Water Discharge Permit Application" - New Mexico

Ground Water Discharge Permit Application is a legal document that was released by the New Mexico Environment Department - a government authority operating within New Mexico.

Form Details:

  • Released on August 1, 2015;
  • The latest edition currently provided by the New Mexico Environment Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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Download "Ground Water Discharge Permit Application" - New Mexico

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NEW MEXICO ENVIRONMENT DEPARTMENT
GROUND WATER QUALITY BUREAU
GROUND WATER DISCHARGE PERMIT
APPLICATION
Instructions for completing the application are included in the form itself and in the Supplemental
Instructions found at the back of the application. You may fill out the application manually, or a
Microsoft Word version may be downloaded from
www.env.nm.gov
(Ground Water Quality) and filled
out electronically. Timely processing of this application is contingent upon the technical completeness of
the submission. Failure to provide all of the information pursuant to Section 20.6.2.3106 NMAC,
following notice of technical deficiency, may result in denial of the application.
Send two complete paper copies AND one electronic copy of this application,
with the filing fee to:
Program Manager
Ground Water Pollution Prevention Section
New Mexico Environment Department
P.O. Box 5469
Santa Fe, NM 87502
Introduction
Facility Name:
GWQB – Date of Receipt
(Department use only)
For Existing Discharge Permits:
DP Number:
Expiration Date:
Type of Discharge
(check one):
Domestic
Industrial
Agricultural
Mining
Type of Application (check appropriate box)
New – new facility
New – existing (unpermitted) facility
Renewal only
Modification only
“modification” includes a change in the location of a discharge, and/or increase in the quantity of
the discharge, and/or a change in the quality of the discharge.
Renewal and Modification
Page 1 of 24
Ground Water Discharge Permit Application Form
Version 1.0, August 1, 2015
NEW MEXICO ENVIRONMENT DEPARTMENT
GROUND WATER QUALITY BUREAU
GROUND WATER DISCHARGE PERMIT
APPLICATION
Instructions for completing the application are included in the form itself and in the Supplemental
Instructions found at the back of the application. You may fill out the application manually, or a
Microsoft Word version may be downloaded from
www.env.nm.gov
(Ground Water Quality) and filled
out electronically. Timely processing of this application is contingent upon the technical completeness of
the submission. Failure to provide all of the information pursuant to Section 20.6.2.3106 NMAC,
following notice of technical deficiency, may result in denial of the application.
Send two complete paper copies AND one electronic copy of this application,
with the filing fee to:
Program Manager
Ground Water Pollution Prevention Section
New Mexico Environment Department
P.O. Box 5469
Santa Fe, NM 87502
Introduction
Facility Name:
GWQB – Date of Receipt
(Department use only)
For Existing Discharge Permits:
DP Number:
Expiration Date:
Type of Discharge
(check one):
Domestic
Industrial
Agricultural
Mining
Type of Application (check appropriate box)
New – new facility
New – existing (unpermitted) facility
Renewal only
Modification only
“modification” includes a change in the location of a discharge, and/or increase in the quantity of
the discharge, and/or a change in the quality of the discharge.
Renewal and Modification
Page 1 of 24
Ground Water Discharge Permit Application Form
Version 1.0, August 1, 2015
If this application is to modify or renew and modify a Discharge Permit, what is the reason for
modification of the Discharge Permit? Describe the proposed changes that would result in modification,
meaning a change in the location of a discharge, and/or an increase in the quantity of the discharge, and/or
a change in the quality of the discharge.
Fees Included with Application
All applicants are required to submit a $100 Application Filing Fee. An additional fee will be assessed
prior to permit issuance. Permit fees are listed in section 20.6.2.3114 NMAC. Make checks payable to:
NMED-Ground Water Quality Bureau
Application Checklist
The following checklist has been provided to assist in ensuring that the application is complete prior to
submission (check all that apply):
Part I. Administrative Completeness
$100 Application Filing Fee
A. General Information
B. Public Notice Information
C. Public Notice Preparation
Part II. Technical Completeness
A. Discharge Volume and Description
B. Identification and Physical Description of Facility
C. Flow Metering
D. Ground Water Monitoring
E. Engineering and Surveying (electronic copies)
F. Land Application Area
Part III. Site-Specific Proposals
Part IV. Electronic (PDF) format of Maps and Logs is required (additional paper copies of maps
and logs are optional and may be requested by the Department if required for review)
A. Surface Soil Survey and Vadose Zone Geology
B. Location Map
C. Flood Zone Map
Page 2 of 24
Ground Water Discharge Permit Application Form
Version 1.0, August 1, 2015
Copies of Application
An applicant applying for a Discharge Permit shall submit two paper copies of the signed application,
and an electronic copy of the signed application including all supporting documentation, to the
address listed below.
Two paper copies – completed and signed
Electronic copy in portable document format (PDF) of the signed application and all supporting
documentation (designs, maps, logs), on the following media (choose one):
Compact disc (CD)/DVD
Flash drive
Send application and fees to the following address:
Program Manager
Ground Water Pollution Prevention Section
New Mexico Environment Department
P.O. Box 5469
Santa Fe, NM 87502
Applicant’s Signature
Signature must be that of the person listed as the legally responsible party on this application (Part I, 2a).
I, the applicant, attest under penalty of law to the truth of the information and supporting documentation
contained in this application for a Ground Water Discharge Permit.
Signature:
Date:
Printed Name:
Title:
Page 3 of 24
Ground Water Discharge Permit Application Form
Version 1.0, August 1, 2015
Part I. Administrative Completeness
General Information
1. Facility Information
See Supplemental Instructions to determine what constitutes a “facility.” The physical address must be
provided. If the facility does not have an address, the location can be described by road intersections,
mile posts, or landmarks, as appropriate. See Supplemental Instructions for additional information.
Facility Name
Discharge Permit #
Physical Address
County
Type of Facility
Driving Directions
2. Contact Information
a)
Applicant Information The applicant is the person or entity (e.g., corporation, partnership,
organization, municipality, etc.) legally responsible for the discharge and for complying with the terms of
the Discharge Permit. If the applicant is an entity, then the name and title of a contact person must be
provided. This application must be signed by the applicant or contact person named here.
Applicant Name
Title
Mailing Address
City
State
Zip
Contact Person
Title
Office Number
Fax Number
Contact
Information
Cell Number
E-mail
b) Facility Operator/Manager Information
Provide the contact information for the facility
operator or manager below. If the facility is required to have an operator certified by the State of New
Mexico, please include the certification level of the operator named here.
Name
Title
Mailing Address
City
State
Zip
Office Number
Fax Number
Contact
Information
Cell Number
E-mail
Cell Number
E-mail
Certification Level
(if applicable)
Page 4 of 24
Ground Water Discharge Permit Application Form
Version 1.0, August 1, 2015
c) Consultant’s Information (if applicable)
If the consultant is a company or organization, then the
name and title of a contact person must be provided here.
Company Name (1)
Company Contact
Mailing Address
City
State
Zip
Contact
Office Number
Fax Number
Information
Cell Number
E-mail
Company Name (2)
Company Contact
Mailing Address
City
State
Zip
Contact
Office Number
Fax Number
Information
Cell Number
E-mail
d) Permit Contact Information (
)
if applicable
If someone other than the contacts listed above is a
primary contact for this application and/or facility, list here.
Name
Title
Mailing Address
City
State
Zip
Contact
Office Number
Fax Number
Information
Cell Number
E-mail
Facility Affiliation
3. Ownership and Real Property Agreements [
20.6.2.7HH NMAC]
The applicant owns (check as appropriate):
The facility
All discharge sites
Some discharge sites
If someone other than the applicant owns the facility or any of the discharge sites, provide ownership
information below. For any portion of the facility where the applicant is not the owner of record, the
applicant shall submit a copy of any lease agreement or other agreement which authorizes the use of the
real property for the duration of the term of the requested permit (typically five years). Lease prices or
other prices may be redacted.
Page 5 of 24
Ground Water Discharge Permit Application Form
Version 1.0, August 1, 2015