Form SFN51601 "Land Treatment Variance Application" - North Dakota

What Is Form SFN51601?

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 April 1, 2007;
  • 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 SFN51601 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 SFN51601 "Land Treatment Variance Application" - North Dakota

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FOR STATE USE ONLY
LAND TREATMENT VARIANCE APPLICATION
File
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT
Clear Fields
County
SFN 51601 (4-2007)
Section 33-20-01.1-14 NDAC states variances may be granted if the Department “finds that by reason of exceptional circumstances strict
conformity with any provisions of this article would cause undue hardship or would be unreasonable, impractical, or not feasible....” Please
consult the Department and any pertinent Land Treatment Guidelines before completing the variance application. Variances may be granted
for a one-time event only. Repeat operations may require a full permit. In addition, applicable portions of the state solid waste management
regulations should be referenced in completing the application. The location of a Land Treatment unit shall comply with NDAC 33-20-04.1-01.,
General Location Standards, Subpart 1., and Subpart 2. Applications must be thorough and complete to be considered. A written Land
Treatment Variance must be received from the Department before disposal 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 - please attach copies of pertinent waste analysis
Approximate Volume
Waste Source/Facility Name
Waste Type
How was the waste generated?
County
Section
Township
Range
Release Site Legal
Description/Street Address
Generator/Owner
Telephone
Street or Mailing Address
City
State
Zip Code
2. Proposed Land Treatment Location and Ownership
Section
Township
Range
County
Total Acreage
Property Owner
Telephone
Street or Mailing Address
City
State
Zip Code
Future Land Use
Present Land Use
3. Maps
Indicate which maps accompany the application (see Instructions in Disposal Site Selection of guideline):
Published Soil Survey Map
Unpublished Soil Survey Map
CFSA Map
Topographic Map
Exact location must be marked on the soil survey or other map.
4. Site and Soil Characteristics and Proposed Operation - attach any assessment of soil nutrients
Distance to Surface Water
Site Slope (percent)
Distance to Nearest Building or
Depth to Seasonal High Water
Feet
Residence (feet)
Table (feet)
Miles
Area of Land to be Used
Land Treatment Procedures and Monitoring
Square Feet
Acres
Expected Date(s) of Fertilizer Application (see Guidelines)
Application Thickness (inches)
Expected Date of Waste Application
Expected Date(s) of Tillage (see Guidelines)
FOR STATE USE ONLY
LAND TREATMENT VARIANCE APPLICATION
File
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF WASTE MANAGEMENT
Clear Fields
County
SFN 51601 (4-2007)
Section 33-20-01.1-14 NDAC states variances may be granted if the Department “finds that by reason of exceptional circumstances strict
conformity with any provisions of this article would cause undue hardship or would be unreasonable, impractical, or not feasible....” Please
consult the Department and any pertinent Land Treatment Guidelines before completing the variance application. Variances may be granted
for a one-time event only. Repeat operations may require a full permit. In addition, applicable portions of the state solid waste management
regulations should be referenced in completing the application. The location of a Land Treatment unit shall comply with NDAC 33-20-04.1-01.,
General Location Standards, Subpart 1., and Subpart 2. Applications must be thorough and complete to be considered. A written Land
Treatment Variance must be received from the Department before disposal 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 - please attach copies of pertinent waste analysis
Approximate Volume
Waste Source/Facility Name
Waste Type
How was the waste generated?
County
Section
Township
Range
Release Site Legal
Description/Street Address
Generator/Owner
Telephone
Street or Mailing Address
City
State
Zip Code
2. Proposed Land Treatment Location and Ownership
Section
Township
Range
County
Total Acreage
Property Owner
Telephone
Street or Mailing Address
City
State
Zip Code
Future Land Use
Present Land Use
3. Maps
Indicate which maps accompany the application (see Instructions in Disposal Site Selection of guideline):
Published Soil Survey Map
Unpublished Soil Survey Map
CFSA Map
Topographic Map
Exact location must be marked on the soil survey or other map.
4. Site and Soil Characteristics and Proposed Operation - attach any assessment of soil nutrients
Distance to Surface Water
Site Slope (percent)
Distance to Nearest Building or
Depth to Seasonal High Water
Feet
Residence (feet)
Table (feet)
Miles
Area of Land to be Used
Land Treatment Procedures and Monitoring
Square Feet
Acres
Expected Date(s) of Fertilizer Application (see Guidelines)
Application Thickness (inches)
Expected Date of Waste Application
Expected Date(s) of Tillage (see Guidelines)
SFN 51601 (4-2007)
Page 2 of 2
5. Local Zoning Approval
Waste disposal must not conflict with local zoning ordinances. Consult with representatives of the applicable zoning jurisdiction (county, township
or city) to determine waste disposal compliance with zoning ordinances. A representative of the local zoning jurisdiction must sign the
application.
The undersigned acknowledge(s) that the above-described waste management or land treatment activities do not conflict with local zoning
ordinances.
Printed Name
Signature of County Official
Date
Address
City
State
Zip Code
Telephone
Printed Name
Date
Signature of City or Township Official
Address
City
State
Zip Code
Telephone
6. Signatures
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who will manage this system or those persons directly responsible for gathering the information, the information submitted
is, to the best of my knowledge and belief, true, accurate, and complete. Activities will be conducted in accordance with Departmental
procedures and as described herein. I am aware that there are significant penalties for submitting false information.
Applicant's Signature
Date
Printed Name
Official Title
Address
City
State
Zip Code
Telephone
Operator's Signature
Date
Printed Name
Official Title
Address
City
State
Zip Code
Telephone
Property Owner's Signature (as listed on page 1)
Date
Printed Name
Official Title
Engineer's or Consultant's Signature
Date
Printed Name
Registration
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
Signature of Staff or Health District Inspector (or other authorized person)
Date
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