LW Form 401E "Application for Liquid Waste Permit or Registration" - New Mexico

What Is LW Form 401E?

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 May 1, 2018;
  • The latest edition provided by the New Mexico Environment Department;
  • 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 LW Form 401E by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download LW Form 401E "Application for Liquid Waste Permit or Registration" - New Mexico

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Application for Liquid Waste Permit or
New Mexico Environment Department
Registration
Environmental Health Bureau
☐ Amendment
☐ Conventional
☐ Conventional Modification
☐ Registration
☐ ATS/ADS
☐ ATS/ADS Modification
☐ ATS Transfer
☐ Commercial
Liquid Waste Processing Number:
Section 1 General Information
Field Office ID:
Application Date:
Name (Property Legal owner, Inc., LLC, partnership, DBA, full legal name):
Facility Name:
Phone:
E-mail address(es):
System Location
Mailing Address (Invoices, permits, official correspondence):
: Physical Address, - (if needed, attach directions)
City:
State:
Zip Code:
City:
State:
Zip Code:
NM
Uniform Property Code:
Date of Record:
Lot Size (0.01 acres):
Total No. LW Systems on Property:
Total Design Flow on Property:
Subdivision:
Subdivision Plat Date:
Unit/Phase:
Block
Lot/Tract
Township
Range
Section
Water Supply Source:
No. Connections:
OSE Well Permit No.
Private Water Well Location (long., lat. or physical address, city, state):
☐Private
☐ Onsite
Irrigation well, flood irrigation area on
Will a petition for variance be submitted
☐Public ☐
Public Water System Name:
Enter all LW permit nos. for lot:
☐ Offsite
lot?
with this application?
Shared
☐ YES
NO ☐
☐ YES
NO ☐
Section 2 Installer Information
Installer Name:
Phone:
Installer Company Name:
☐Corp., Inc.
Mailing Address (street / PO Box, City, State, Zip):
E-mail address:
☐ LLC
☐ Sole Prop.
CID License Classification:
CID License No.:
☐LP, LLP
☐MM-1
☐MM-98
☐MS-1
☐MS-3
Homeowner
I am a licensed contractor by the State of New Mexico Regulation Licensing Department, Construction Industries Division (CID). I will either personally install the work myself or authorize
my employee(s), ______________________________________________________(named here) to provide the services and labor for this permit application under my direct supervision.
Section 3 Authentication / Verification
By signing below I attest that the information in this application is correct and true to the best of my knowledge. I understand the issuing of this permit does not relieve me from the
responsibility of complying with all applicable provisions of the New Mexico Plumbing Code and the New Mexico Liquid Waste Disposal and Treatment Regulations. Obtaining this permit
does not relieve me from the responsibility of obtaining any permit required by state, city or county regulation or ordinance or other requirements of state or federal law.
Page must be
Printed Name :
Signature :
Date Signed:
☐ Contractor
attached for each
☐ Authorized Rep.
proposed system
☐ Home Owner
on lot
NMED CONSTRUCTION APPROVAL
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Construct No.
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
NMED LIQUID WASTE FEES
Conventional-New $100
Conventional Modification $50
Registration $100
ATS/ADS - New $150
ATS/ADS Modification $75
Commercial $150
Variance $50
Total Fee Paid
Date Paid
Payment Received By
FINAL INSPECTION OF LW SYSTEM
Final Inspection Date:
NMED Inspector Name Printed:
☐Installation Approved
☐ Final Inspection
Conducted by NMED
☐Installation Approved with Conditions
Photo inspection date::
Date photos and Completed
(see inspection form for conditions)
☐Contractor photo
Form Received by NMED::
☐Installation Not Approved
inspection authorized:
NMED OPERATIONAL APPROVAL
A permit for operation of the Liquid Waste system described herein is hereby:
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Operate No.:
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
LW Form 401E Application for Liquid Waste Permit or Registration 2018 Rev 5-1-18
Application for Liquid Waste Permit or
New Mexico Environment Department
Registration
Environmental Health Bureau
☐ Amendment
☐ Conventional
☐ Conventional Modification
☐ Registration
☐ ATS/ADS
☐ ATS/ADS Modification
☐ ATS Transfer
☐ Commercial
Liquid Waste Processing Number:
Section 1 General Information
Field Office ID:
Application Date:
Name (Property Legal owner, Inc., LLC, partnership, DBA, full legal name):
Facility Name:
Phone:
E-mail address(es):
System Location
Mailing Address (Invoices, permits, official correspondence):
: Physical Address, - (if needed, attach directions)
City:
State:
Zip Code:
City:
State:
Zip Code:
NM
Uniform Property Code:
Date of Record:
Lot Size (0.01 acres):
Total No. LW Systems on Property:
Total Design Flow on Property:
Subdivision:
Subdivision Plat Date:
Unit/Phase:
Block
Lot/Tract
Township
Range
Section
Water Supply Source:
No. Connections:
OSE Well Permit No.
Private Water Well Location (long., lat. or physical address, city, state):
☐Private
☐ Onsite
Irrigation well, flood irrigation area on
Will a petition for variance be submitted
☐Public ☐
Public Water System Name:
Enter all LW permit nos. for lot:
☐ Offsite
lot?
with this application?
Shared
☐ YES
NO ☐
☐ YES
NO ☐
Section 2 Installer Information
Installer Name:
Phone:
Installer Company Name:
☐Corp., Inc.
Mailing Address (street / PO Box, City, State, Zip):
E-mail address:
☐ LLC
☐ Sole Prop.
CID License Classification:
CID License No.:
☐LP, LLP
☐MM-1
☐MM-98
☐MS-1
☐MS-3
Homeowner
I am a licensed contractor by the State of New Mexico Regulation Licensing Department, Construction Industries Division (CID). I will either personally install the work myself or authorize
my employee(s), ______________________________________________________(named here) to provide the services and labor for this permit application under my direct supervision.
Section 3 Authentication / Verification
By signing below I attest that the information in this application is correct and true to the best of my knowledge. I understand the issuing of this permit does not relieve me from the
responsibility of complying with all applicable provisions of the New Mexico Plumbing Code and the New Mexico Liquid Waste Disposal and Treatment Regulations. Obtaining this permit
does not relieve me from the responsibility of obtaining any permit required by state, city or county regulation or ordinance or other requirements of state or federal law.
Page must be
Printed Name :
Signature :
Date Signed:
☐ Contractor
attached for each
☐ Authorized Rep.
proposed system
☐ Home Owner
on lot
NMED CONSTRUCTION APPROVAL
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Construct No.
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
NMED LIQUID WASTE FEES
Conventional-New $100
Conventional Modification $50
Registration $100
ATS/ADS - New $150
ATS/ADS Modification $75
Commercial $150
Variance $50
Total Fee Paid
Date Paid
Payment Received By
FINAL INSPECTION OF LW SYSTEM
Final Inspection Date:
NMED Inspector Name Printed:
☐Installation Approved
☐ Final Inspection
Conducted by NMED
☐Installation Approved with Conditions
Photo inspection date::
Date photos and Completed
(see inspection form for conditions)
☐Contractor photo
Form Received by NMED::
☐Installation Not Approved
inspection authorized:
NMED OPERATIONAL APPROVAL
A permit for operation of the Liquid Waste system described herein is hereby:
☐ Granted
☐ Granted with conditions
☐ Denied
☐ Cancelled
Conditions or Reasons for Denial:
NMED Permit to Operate No.:
NMED Inspector Name Printed:
NMED Inspector Signature:
Date:
LW Form 401E Application for Liquid Waste Permit or Registration 2018 Rev 5-1-18
Application for Liquid Waste Permit or
New Mexico Environment Department
Registration
Environmental Health Bureau
If your lot has more than one LW system, you must fill out a separate application for each system. The site plan drawing must show all liquid waste
Liquid Waste Processing Number:
systems located on your lot. Existing permitted systems must be identified with their LW Permit #. New, modified or unpermitted systems must be
clearly labelled on the site plan. NMED agents are not authorized to amend or complete any portion of this application.
Treatment & Disposal System Design
Section 1 Design Flow, Hydrology, and Soil Description
A. Wastewater Sources & Design Flow Calculations
B. Hydrology Data
C. Soil Description:
AR
Depth from ground surface to:
Feet
Type
Facility
Units (enter number)
(Q) Flow, calculated: gpd
Bedrooms:
Total flow:
☐Type Ia: Coarse Sand
☐Single Family Residence
Seasonal High Water table
1.25
(or up to 30% gravel)
No. Units:
Calculation Sheet Attached:
Total flow:
☐Type Ib: Medium Sand,
☐Multiple Family Units
Bedrock, caliche, tight clay
2.0
☐YES NO☐
Loamy Sand
Method of Design Flow Calculation:
Total flow:
☐Commercial / Institution (type):
☐Type II: Sandy Loam,
☐ Table 201.1
Gravel, cobbles, highly permeable soil
2.0
☐ PE (Calc. Sheet)
Fine Sand, Loam
☐Other:
☐Water Meter Data Attached
No. of Units:
Total flow:
☐Type III: Silt, Silt Loam,
☐Cluster
Test Hole / Soil Borings Used:
☐ YES NO ☐
2.0
☐Other (type):
Clay Loam, Silty Clay
Soil Classification Methodology used:
Loam, Sandy Clay Loam
☐ Jar Test
Q
☐Type IV: Sandy Clay,
☐Laboratory:
☐ Hand Sampling
Total Flow for this LW System:
5.0
Silty Clay, Clay
☐Other:
☐Sieve
Section 2. Treatment Unit and Pump Design:
Primary Treatment
No. Septic Tank(s)
Manufacturer:
Series / Model / Certification No.:
Capacity (gallons)
Burial Depth:
Unit
1
☐Septic Tank(s)
Manufacturer:
Series / Model:
Capacity (gallons)
Burial Depth:
☐Pump Tank
2
Manufacturer:
Series / Model:
Pump Curve Attch’d:
Effluent Pump:
☐Pump
YES NO
☐YES NO☐
☐Dual Pump
Manufacturer:
Series / Model:
Capacity (gallons)
Burial Depth:
☐Standard
☐Secondary
☐Required
☐Conditional
☐Voluntary
☐Tertiary
☐Experimental
3
Manufacturer:
Series / Model:
Notes:
☐UV
☐Required
☐Ozone
Disinfection
☐Voluntary
☐Chlorine
Section 3 Disposal System Design, Components and Calculations
Q
AR
Min. Sq. Ft. Required:
X
=
A. Minimum Required absorption area, calculated
(Multiply Design Flow (Q) times Application Rate (AR):
B. Design Components:
☐Distribution Box
☐ Drop Box
☐Alternating Drainfield Valve
☐ Other:
☐Tee
Trench Width:
Depth Gravel Below Pipe:
Total Linear Feet:
No. of Trenches:
Max Trench Depth:
Length, each trench:
Trench Spacing (ft):
Proposed Sq. Ft.:
☐Pipe & Gravel
Mfr. Model No & Sizing Credit (sf/lf, or unit).:
Total Linear Feet:
No. of Units:
Max Trench Depth:
Length, each trench:
Trench Spacing (ft):
Proposed Sq. Ft.:
☐Chamber
☐Synthetic Agg.
☐Other:
Dimensions (L x W):
Depth below invert:
Proposed Sq. Ft.:
Max Trench Depth:
Notes:
☐Seepage Pit
☐Absorption Bed
Section 4 Alternative Disposal System (ADS) Design, Components and Calculations
For all ADS’s – calculation sheets & site plan drawings (plan view with cross section views) must be submitted with this permit application.
☐Effluent Irrigation
☐Sand-Lined Trench
☐Bottomless Sand Filters
☐Wisconsin Mound
☐Elevated System
☐Unlined ET Bed
Re-use
Sand ASTM Specs Attached?
Sand ASTM Specs Attached?
☐ YES NO ☐
☐ YES NO ☐
☐Drip Irrigation
☐LPD
☐LPP
☐Graywater
☐Split Flow
☐Other (description):
(complete holding tank section & septic tank & conventional disposal section)
☐Wetland
No. of Tank(s)
Manufacturer:
NM Certification No.:
Capacity:
Burial Depth:
High Water Alarm at 80%?
☐Holding
☐ YES NO ☐
Tank
Liner Material & Thickness (mils):
Liner Material & Thickness (mils):
Dimensions (L x W ) & sq. ft.:
Dimensions (L x W ) & sq. ft.:
☐Lined ET Bed
☐Lined Lagoon
Sand ASTM Specs Attached?
☐ YES NO ☐
☐Privy (outhouse)
☐Other (description):
☐Vault
Section 5
1. Does proposed system meet all setbacks required per Table 302.1?
☐ YES NO ☐
Setbacks / Site
2. Site plan attached which shows all structures, LW systems, and wells / waters within 200’ with all setbacks clearly shown?
☐ YES NO ☐
Plan &
3. If ATS or ADS, all requirements under section 403 are submitted, including calculations and drawings?
☐ N/A ☐ YES NO ☐
Attachments
(check those that
Supporting Documents Included:
☐Warranty Deed
☐Tax Bill
☐Survey
☐Plat
☐Floorplan
☐Other:
apply)
LW Form 401E Application for Liquid Waste Permit or Registration 2018 Rev 5-1-18
Table 302.1 Minimum setback and clearance requirements
Building
Disposal
Seepage
From:
To:
Treatment Unit*
Sewer
Field
Pit
Property lines
clear
5 ft.
5 ft.
8 ft.
Building or structure
2 ft.
5 ft.
8 ft.
8 ft.
Distribution box
--
--
5 ft.
5 ft.
Disposal field
--
10 ft.*****
4 ft****
10 ft.
Seepage pit
--
10 ft.
10 ft.
12 ft.
Drinking water line******
- private
1 ft.
10 ft.
10 ft.
10 ft.
- public
10 ft.
10 ft.
10 ft.
10 ft.
Drinking water source/well
- private
50 ft.
50 ft.
100 ft.
100 ft.
- public
50 ft.
100 ft.
200 ft.
200 ft.
Irrigation well
50 ft.
50 ft.
100 ft.
100 ft.
Lined canals
--
10 ft.**
10 ft.**
10 ft.**
Unlined canals, drainage ditches
--
15 ft.**
25 ft.**
25 ft.**
Arroyos
--
15 ft.**
25 ft.**
25 ft.**
Other watercourses
Waters of the state
--
50 ft.
100 ft.
100 ft.
Retention/detention area
--
15 ft.
15 ft.
15 ft.
or flood irrigation areas
Seasonal high water table,
4 ft. to
4 ft. to
--
--
bedrock and other impervious
bottom of
bottom of
layers***
system
system
(1) * Applies to privy pits, enclosed systems, other liquid waste treatment units.
(2) ** Plus depth of channel.
(3) *** Unlined privy pits shall provide clearance of at least four feet.
(4) **** Plus two feet for each additional foot of depth below the invert of the distribution pipe.
(5) ***** May be five feet when Schedule 40 PVC/DWV pipe is used.
(6) ******Or applicable plumbing code.
Bedrooms, Design Flow, Capacity of Septic Tanks,
Table 301.1
combined tables, combines 201P and table 201.2
Single
Design
Other uses
Minimum
Total Design Flow
Minimum Lot Size
gpd
Acres
family
Flow (gpd-
maximum
septic tank
dwelling,
gallons
fixture
capacity in
375 or less
0.75
number of
per day)
units*
gallons served
bedrooms
440
0.88
1
150
10
750
500
1.00
2
300
12
1000
750
1.50
3
375
12
1000
4
440
15
1200
1125
2.25
5
500
20
1500
1500
3.00
6
550
20
1500
7
600
27
2000
1875
3.75
8
650
27
2000
2000
4.00
9
700
27
2000
29
2250
32
2500
35
2750
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