Form SFN58981 "Nddot Projects-Inert Waste Beneficial Use Application" - North Dakota

What Is Form SFN58981?

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 September 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 SFN58981 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 SFN58981 "Nddot Projects-Inert Waste Beneficial Use Application" - North Dakota

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NDDOT PROJECTS-INERT WASTE BENEFICIAL USE APPLICATION
NORTH DAKOTA DEPARTMENT OF HEALTH
Telephone:
701-328-5166
DIVISION OF WASTE MANAGEMENT
Clear Fields
Fax Number: 701-328-5200
SFN 58981 (9-2009)
Website: www.ndhealth.gov/wm
This form is for contractors awarded a project by the North Dakota Department of Transportation (NDDOT) only.
Please read the Department's Guideline 22 - Inert Waste Disposal Variance before completing this beneficial use application.
Applications must be thorough and complete to be considered. Adequate maps and project information should be attached
with application. This form must be completed, signed, and returned to the Department before inert waste beneficial use begins.
Please call the Department's Solid Waste Program at 701-328-5166 if there are any questions.
Section 1. Inert Waste Description
Waste Source
Waste Project Number
County
Date of Contract
Completion Date
Site Description
Project Location
Responsible Party (contractor awarded bid)
Waste Type
Waste Volume
Does waste contain asphalt, rebar, or asbestos?
Yes
No
Section 2. Reason or Justification for Beneficial Use (Please describe beneficial use project)
Section 3. Proposed Inert Waste Beneficial Use Location (please be as concise as possible)
Street
City
Total Acreage
SITE
Section
Township
Range
County
LOCATION
OR
1/4
1/4
Name of Property Owner
Telephone Number
Street Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Present Land Use
Future Land Use
Section 4. Contractor for Waste Beneficial Use (List any subcontractors on a separate sheet. The main contractor shall
remain liable for beneficial use activities.). Please note that project payments may be suspended subject to successful
completion of any beneficial use activity
Name
Contact
Street Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Telephone Number
Mobile/Cell Phone
Equipment Used for Waste Beneficial Use
Section 5. Maps Mark 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
NDDOT PROJECTS-INERT WASTE BENEFICIAL USE APPLICATION
NORTH DAKOTA DEPARTMENT OF HEALTH
Telephone:
701-328-5166
DIVISION OF WASTE MANAGEMENT
Clear Fields
Fax Number: 701-328-5200
SFN 58981 (9-2009)
Website: www.ndhealth.gov/wm
This form is for contractors awarded a project by the North Dakota Department of Transportation (NDDOT) only.
Please read the Department's Guideline 22 - Inert Waste Disposal Variance before completing this beneficial use application.
Applications must be thorough and complete to be considered. Adequate maps and project information should be attached
with application. This form must be completed, signed, and returned to the Department before inert waste beneficial use begins.
Please call the Department's Solid Waste Program at 701-328-5166 if there are any questions.
Section 1. Inert Waste Description
Waste Source
Waste Project Number
County
Date of Contract
Completion Date
Site Description
Project Location
Responsible Party (contractor awarded bid)
Waste Type
Waste Volume
Does waste contain asphalt, rebar, or asbestos?
Yes
No
Section 2. Reason or Justification for Beneficial Use (Please describe beneficial use project)
Section 3. Proposed Inert Waste Beneficial Use Location (please be as concise as possible)
Street
City
Total Acreage
SITE
Section
Township
Range
County
LOCATION
OR
1/4
1/4
Name of Property Owner
Telephone Number
Street Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Present Land Use
Future Land Use
Section 4. Contractor for Waste Beneficial Use (List any subcontractors on a separate sheet. The main contractor shall
remain liable for beneficial use activities.). Please note that project payments may be suspended subject to successful
completion of any beneficial use activity
Name
Contact
Street Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Telephone Number
Mobile/Cell Phone
Equipment Used for Waste Beneficial Use
Section 5. Maps Mark 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 58981 (9-2009)
Page 2
Section 6. Beneficial Use Site and Soil Characteristics (NRCS Information) - Include NRCS Soil Maps, Soil
Description, and Topographic Map
Site Slope (percent)
Distance to Surface Water (feet)
Soil Type and Texture
Depth to Seasonal High Water Table (feet)
Section 7. Beneficial Use Site Design (enclose appropriate diagrams, maps, cross sections, and narrative)
Site Plan View
One to Two Cross Sections Showing: Site Design
Waste Placement
Describe Stormwater/Erosion Controls
Final Vegetation
Application must include diagrams of these components — are these enclosed?
Yes
No
Section 8. District
Name of ND DOT District
District Telephone Number
U.S.A.C.E. Approval?
Name of District Engineer
Yes
No
N/A
District Address
City
Zip Code
For sites located in wetlands, approval from the Division of Water Quality and/or U.S. Army Corps of Engineers may be required.
Section 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 compliance with zoning ordinances. A representative of the local zoning
jurisdiction must sign the application.
Print Name
Zoning Jurisdiction
Signature
Date
Section 10. Signatures. Signatures are required by the party (contractor) responsible for the waste and the owner of
the 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 will not be disposed and/or will be removed prior to demolition. The
inert waste beneficial use site will be operated and closed according to the Department's Guideline 22 and Guideline 38.
Contractor Signature
Date
Beneficial Use Site Owner: Placement on my property is acceptable to me and I am knowledgeable of the Federal and State
requirements. The site will be maintained after closure to minimize erosion and prevent exposure of waste materials. State
inspectors may review and inspect the property described above. No further placement other than that approved by the
Department will occur on this site. An “Affidavit and Notice of Disposal Facility” will be completed according to Guideline 22
and filed with the County Register of Deeds. The Department will be provided with a certified copy of the Affidavit within thirty
(30) days of filing.
Owner Signature
Date
(Attach additional pages if needed)
Return completed application and
ND Department of Health
supplemental forms/pages to:
Environmental Health Section
Division of Waste Management
918 E. Divide Ave., 3rd Floor
Bismarck, ND 58501-1947
Telephone: (701) 328-5166
Fax: (701) 328-5200
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