Form SFN58980 "Inert Waste Beneficial Use Application" - North Dakota

What Is Form SFN58980?

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

Form Details:

  • Released on July 1, 2009;
  • The latest edition provided by the North Dakota Department of Health;
  • 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 fillable version of Form SFN58980 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN58980 "Inert Waste Beneficial Use Application" - North Dakota

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FOR STATE USE ONLY
INERT WASTE BENEFICIAL USE APPLICATION
File
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT
Clear Fields
County
SFN 58980 (7-2009)
Please read the Department's Inert Waste Disposal Variance Guideline before completing this beneficial use application. In addition,
applicable portions of the state solid waste management regulations should be referenced in completing the applications. The source, type,
and characteristics of your waste will determine which rules apply. Applications must be thorough and complete to be considered. A written
Beneficial Use Variance must be received from the Department before inert waste beneficial use may begin. Please call the Department's
Solid Waste Program at (701) 328-5166 to coordinate your application with a Department staff member.
1. Waste Description
Waste Volume
Waste Source
Waste Type
General Geographic Location
County
Legal Description or Street Address
Responsible Party
Telephone Number
Address
City
State
Zip Code
2. Reason or Justification for Beneficial Use (Please describe beneficial use project)
3. Proposed Inert Waste Beneficial Use Location
Township
Range
County
of Section:
Total Acreage
Property Owner
Telephone Number
Address
City
State
Zip Code
Future Land Use
Present Land Use
4. Contractor For Waste Beneficial Use
Name
Contact
Address
City
State
Zip Code
Telephone Number
Mobile Telephone Number
Equipment Used For Waste Beneficial Use
5. Maps
Indicate which maps accompany the application (see Inert Waste Beneficial Use Requirements in Guideline 38):
Published Soil Survey Map
Unpublished Soil Survey Map
CFSA Map
Topographic Map
FOR STATE USE ONLY
INERT WASTE BENEFICIAL USE APPLICATION
File
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT
Clear Fields
County
SFN 58980 (7-2009)
Please read the Department's Inert Waste Disposal Variance Guideline before completing this beneficial use application. In addition,
applicable portions of the state solid waste management regulations should be referenced in completing the applications. The source, type,
and characteristics of your waste will determine which rules apply. Applications must be thorough and complete to be considered. A written
Beneficial Use Variance must be received from the Department before inert waste beneficial use may begin. Please call the Department's
Solid Waste Program at (701) 328-5166 to coordinate your application with a Department staff member.
1. Waste Description
Waste Volume
Waste Source
Waste Type
General Geographic Location
County
Legal Description or Street Address
Responsible Party
Telephone Number
Address
City
State
Zip Code
2. Reason or Justification for Beneficial Use (Please describe beneficial use project)
3. Proposed Inert Waste Beneficial Use Location
Township
Range
County
of Section:
Total Acreage
Property Owner
Telephone Number
Address
City
State
Zip Code
Future Land Use
Present Land Use
4. Contractor For Waste Beneficial Use
Name
Contact
Address
City
State
Zip Code
Telephone Number
Mobile Telephone Number
Equipment Used For Waste Beneficial Use
5. Maps
Indicate which maps accompany the application (see Inert Waste Beneficial Use Requirements in Guideline 38):
Published Soil Survey Map
Unpublished Soil Survey Map
CFSA Map
Topographic Map
SFN 58980 (7-2009)
Page 2 of 2
6. Beneficial Use Site And Soil Characteristics
Distance to Surface Water (feet)
Site Slope (percent)
Depth to Seasonal High Water Table (feet)
Soil Type and Texture
7. Beneficial Use Site Design (Enclose appropriate diagrams, maps, cross sections, and narrative.)
Site Plan View
One to Two Cross Sections Showing: Trench Depth
Waste Placement
Final Cover Design
Final Vegetation
Diagrams Enclosed of These Components
Yes
No
8. Supplemental Application Forms
Indicate which supplemental forms are completed and attached to the application:
Application for Open Burn Variance
Notification of Demolition and Renovation
Other
For sites located in wetlands, approval from the Division of Water Quality and/or U.S. Army Corps of Engineers may be required.
9. Local Zoning Approval
Inert waste beneficial use must not conflict with local zoning ordinances. Consult with representatives of the applicable zoning jurisdiction
(county, township or city) to determine inert beneficial use disposal compliance with zoning ordinances. A representative of the local zoning
jurisdiction must sign the application.
I, the undersigned, certify that inert waste beneficial use at the location described on this application does not conflict with local zoning
ordinances.
Printed Name
Date
Signature
Printed Name
Date
Zoning Jurisdiction
10. Signatures
Signatures are required by the following: the party responsible for the waste and/or owner of the property scheduled for demolition; the
contractor; and owner of inert waste beneficial use site.
Party Responsible for Waste: The inert waste and/or the structure scheduled for demolition has been inspected. Prohibited waste or materials
described in the Department's “Guideline 22 - Inert Waste Disposal Variance” and "Guideline 38-Beneficial Use of Inert Waste" will not be disposed
and/or will be removed from the structure prior to demolition.
Printed Name
Date
Signature
Contractor: The inert waste beneficial use site will be operated and closed according to Guideline 38.
Printed Name
Date
Signature
Beneficial Use Site Owner: A notification of inert waste disposal will be filed with the County Register of Deeds. The notification will be
completed according to “Guideline 22 - Inert Waste Disposal Variance.” The Department will be provided with a certified copy of the notice within
thirty (30) days of filing.
Printed Name
Date
Signature
Mail this application and supplemental forms to:
ND Department of Health
Division of Waste Management
918 E. Divide Ave., 3rd Fl.
Bismarck, ND 58501-1947
Telephone: 701-328-5166 · Fax: 701-328-5200 · Website: www.ndhealth.gov/wm
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