Form LW405 "Application for Liquid Waste Variance" - New Mexico

What Is Form LW405?

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 July 1, 2020;
  • 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 printable version of Form LW405 by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download Form LW405 "Application for Liquid Waste Variance" - New Mexico

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Application for Liquid Waste Variance
New Mexico Environment Department
Environmental Health Bureau
LW 405
Liquid Waste Program
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, County - (if needed, attach directions)
City:
State:
Zip Code:
City:
State:
Zip Code:
Uniform Property Code:
Date of Record:
Lot Size (0.01
Total No. LW Systems on Property:
Total Design Flow on Property:
acres):
Subdivision:
Subdivision Plat Date:
Unit/Phase
Block
Lot/Tract
Township
Range
Section
Section 2 Variance Request
I hereby apply to the New Mexico Environment Department (NMED) for a variance to the requirement(s) of the Liquid Waste
Disposal and Treatment Regulations (20.7.3 NMAC). I believe that the issuance of a variance to the requirement(s) will not result
in the degradation of any body of water or be a hazard to public health, and that the proposed system will provide environment and
public health protection at least equivalent to the minimum protection required by the section from which I am requesting a variance.
Section(s) of the Liquid Waste Disposal Regulations from which I am requesting a variance:
Section
Sub-section
Specific conditions requiring the variance
Section 3 Justification (choose the one that is applicable):
Initials:
I am unable to install a compliant onsite (conventional, alternative technology, or alternative disposal) system
on said property. You must provide a statement demonstrating why compliant discharging and non-
discharging systems cannot be installed on said property, provide site diagram details.
Circle:
Discharging System cannot be installed: Explain below
Non-discharging system cannot be installed: Explain below
Form LW 405 200701
1 of 4
NMED Received Date Stamp Here
Application for Liquid Waste Variance
New Mexico Environment Department
Environmental Health Bureau
LW 405
Liquid Waste Program
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, County - (if needed, attach directions)
City:
State:
Zip Code:
City:
State:
Zip Code:
Uniform Property Code:
Date of Record:
Lot Size (0.01
Total No. LW Systems on Property:
Total Design Flow on Property:
acres):
Subdivision:
Subdivision Plat Date:
Unit/Phase
Block
Lot/Tract
Township
Range
Section
Section 2 Variance Request
I hereby apply to the New Mexico Environment Department (NMED) for a variance to the requirement(s) of the Liquid Waste
Disposal and Treatment Regulations (20.7.3 NMAC). I believe that the issuance of a variance to the requirement(s) will not result
in the degradation of any body of water or be a hazard to public health, and that the proposed system will provide environment and
public health protection at least equivalent to the minimum protection required by the section from which I am requesting a variance.
Section(s) of the Liquid Waste Disposal Regulations from which I am requesting a variance:
Section
Sub-section
Specific conditions requiring the variance
Section 3 Justification (choose the one that is applicable):
Initials:
I am unable to install a compliant onsite (conventional, alternative technology, or alternative disposal) system
on said property. You must provide a statement demonstrating why compliant discharging and non-
discharging systems cannot be installed on said property, provide site diagram details.
Circle:
Discharging System cannot be installed: Explain below
Non-discharging system cannot be installed: Explain below
Form LW 405 200701
1 of 4
NMED Received Date Stamp Here
Application for Liquid Waste Variance
New Mexico Environment Department
Environmental Health Bureau
LW 405
Liquid Waste Program
System Location
Liquid Waste Processing Number:
Name (Property Legal owner, Inc., LLC, partnership, DBA):
: Physical Address, County - (if needed, attach directions)
Section 4 Equal Protection
How does the proposed design provide equal or greater protection?
Initials:
Proposed
Proposed system is designed
to what Section(s):
system meets
the indicated
section and
described as:
Equally
Section Varianced:
protective
measure(s)
Equally
Other Section Varianced:
protective
measure(s)
Section 5 Adjacent Property Owner Notifications
All adjacent property owners sharing a common boundary and within 100 feet if sharing a common right- of-way have been notified by,
certified mail, or door to door, of my intent to apply for this variance. If a shared well is located on the property, all parties sharing the
well must be notified. If any property boundary is over 1,000 feet from the system, notification is not required.
(Note:
This verbiage has been revised for simplicity and clarification.)
Notification Method (letter hand delivered, certified mail receipt #):
Adjacent Property ID
Adjacent Property Owner Name Printed
Adjacent property owners not notified should be listed and the basis
Date Notified:
(UPC or Parcel number):
(as ownership or tax records demonstrate)
for non-notification expressed herein.
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Form LW 405 200701
2 of 4
NMED Received Date Stamp Here
Application for Liquid Waste Variance
New Mexico Environment Department
Environmental Health Bureau
LW 405
Liquid Waste Program
System Location
Liquid Waste Processing Number:
Name (Property Legal owner, Inc., LLC, partnership, DBA):
: Physical Address, County - (if needed, attach directions)
List all official documents enclosed utilized to determine proper notifications were made. These documents must be from official
jurisdictional agencies that can authenticate the information. The listed items are an example of documents acceptable: Survey, plat,
aerial satellite photo with property boundaries, property tax information
Dated
Source and description:
Number of Pages
Document
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Requests for information about the requested variance and comments may be submitted to the NMED field office located at the full
complete USPS address as indicated below:
Field Office:
Mailing Address:
City:
State:
Zip
Phone:
Physical Address (non-mailing):
City:
State:
Zip
Notifications Attached (choose one):
Number of Certified Receipts:
Yes
N/A
Copy of the notification letter with all certified receipts.
Number of signed applications
Yes
N/A
Copy of variance application with signatures for each person notified.
Number of signature sheets:
Yes
N/A
Signature sheet(s) with a copy of the document (s) provided.
Property owners notified must be those of legal ownership as represented by official documents (warranty deeds, county tax
records). If the applicant is acting as: (a) executor of an estate, (b) corporate officer, (c) authorized representative (power of
attorney) documentation must be provided to demonstrate authorization. If the applicant is an inheritor and ownership of
property has not been probated appropriate documents will be required to demonstrate proper authorization or the application
will be denied.
Applicants Printed Name:
Applicants Signature:
Date:
The Department will take action on the variance application after a minimum of ten (10) but no later than twenty (20) working
days following receipt of the completed variance application. This includes all adjacent property owner notifications. Please note
that all interested parties must have maximum afforded time to file notice with the indicated field office.
The Applicant may request a hearing in accordance with Section 406 of the Liquid Waste Disposal and Treatment Regulations
20.7.3 NMAC if dissatisfied with the action taken by the Department. The request must be made in writing within fifteen (15)
working days of notice of the Department's decision.
Application Received by (printed name and title):
Initials:
Received Date:
Form LW 405 200701
3 of 4
NMED Received Date Stamp Here
Application for Liquid Waste Variance
New Mexico Environment Department
Environmental Health Bureau
LW 405
Liquid Waste Program
System Location
Liquid Waste Processing Number:
Name (Property Legal owner, Inc., LLC, partnership, DBA):
: Physical Address, County - (if needed, attach directions)
Section 6 NMED ACTION
Person(s) making a written submission concerning this variance application
(NMED attach letter with additional info if needed)
Name
Address
Date Received:
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Incomplete: This application was declared INCOMPLETE as indicated below:
Date Incomplete:
Reasons:
Complete: This application was declared COMPLETE
Date Complete:
THE VARIANCE IS HEREBY (circle applicable choices):
The Department has reviewed the request for a variance and it appears that the proposed system will
(circle one, strike the other)
NOT MEET the requirements for granting a variance as specified in Section 405 of the Liquid Waste Disposal and Treatment
Regulations.
DENIED
This variance has been denied for the indicated reasons:
Date Denied:
The Department has reviewed the request for a variance, and it appears that the proposed system will
(circle one, strike the other)
MEET the requirements for granting a variance as specified in Section 405 of the Liquid Waste Disposal and Treatment
Regulations.
GRANTED
Granted subject to conditions:
Date Granted:
Conditions:
Date and method NMED notified Applicant:
NMED LIQUID WASTE FEES
☐ Variance small system $100 (up to 2,000 gpd)
☒ Variance large system $250 (2,001 to 5,000 gpd)
Total Fee Paid
Date Paid
Payment Received By
The variance will remain effective for the following period:
Expiration Date:
NMED Official Printed name and title:
Signature:
Date:
Form LW 405 200701
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NMED Received Date Stamp Here
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