Fillable Registration New Mexico Environment Department Environmental Health Bureau (State of New Mexico)

Fill Online, Printable, Fillable, Blank Registration New Mexico Environment Department Environmental Health Bureau (State of New Mexico) Form

Use Fill to complete blank online STATE OF NEW MEXICO (NM) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Registration New Mexico Environment Department Environmental Health Bureau (State of New Mexico)

On average this form takes 50 minutes to complete

The Registration New Mexico Environment Department Environmental Health Bureau (State of New Mexico) form is 2 pages long and contains:

  • 0 signatures
  • 71 check-boxes
  • 166 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Mexico

BROWSE STATE OF NEW MEXICO (NM) FORMS
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
New Mexico Environment Department
Environmental Health Bureau
Application for Liquid Waste Permit or
Registration
LW Form 401E Application for Liquid Waste Permit or Registration 2018 Rev 5-1-18
☐
Conventional
☐
Conventional Modification
☐
Registration
☐
ATS/ADS
☐
ATS/ADS Modification
☐
ATS Transfer
☐
Commercial
Section 1 General Information
NMED USE
ONLY
Liquid Waste Processing Number:
Name (Property Legal owner, Inc., LLC, partnership, DBA, full legal name):
Field Office ID:
Application Date:
Facility Name:
Phone:
E-mail address(es):
System Location
: Physical Address, - (if needed, attach directions)
Mailing Address (Invoices, permits, official correspondence):
City:
State:
Zip Code:
City:
State:
Zip Code:
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):
☐ Onsite
☐ Offsite
☐Private
☐Public ☐
Shared
Public Water System Name:
Irrigation well, flood irrigation area on
lot?
☐ YES NO ☐
Enter all LW permit nos. for lot:
Will a petition for variance be submitted
with this application?
☐ YES NO ☐
Section 2 Installer Information
Installer Name:
Phone:
Installer Company Name:
☐Corp., Inc.
☐ LLC
☐ Sole Prop.
☐LP, LLP
Mailing Address (street / PO Box, City, State, Zip):
E-mail address:
CID License Classification:
CID License No.:
☐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
attached for each
proposed system
on lot
☐
Contractor
☐ Authorized Rep.
☐ Home Owner
Printed Name :
Signature :
Date Signed:
NMED USE ONLY NMED USE ONLY NMED USE ONLY NMED USE
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
Conducted by NMED
Final Inspection Date:
NMED Inspector Name Printed:
☐Installation Approved
☐Installation Approved with Conditions
(see inspection form for conditions)
☐Installation Not Approved
☐Contractor photo
inspection authorized:
Photo inspection date::
Date photos and Completed
Form Received by NMED::
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:
NM
New Mexico Environment Department
Environmental Health Bureau
Application for Liquid Waste Permit or
Registration
LW Form 401E Application for Liquid Waste Permit or Registration 2018 Rev 5-1-18
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
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.
Liquid Waste Processing Number:
Treatment & Disposal System Design
Section 1 Design Flow, Hydrology, and Soil Description
A. Wastewater Sources & Design Flow Calculations
B. Hydrology Data
C. Soil Description:
Facility
Units (enter number) (Q) Flow, calculated: gpd
Depth from ground surface to:
Feet
Type
AR
☐Single Family Residence
Bedrooms:
Total flow:
Seasonal High Water table
☐Type Ia: Coarse Sand
(or up to 30% gravel)
1.25
☐Multiple Family Units
No. Units:
Calculation Sheet Attached:
Total flow:
Bedrock, caliche, tight clay
☐Type Ib: Medium Sand,
Loamy Sand
2.0
☐YES NO☐
☐Commercial / Institution (type):
Method of Design Flow Calculation:
☐ Table 201.1
☐ PE (Calc. Sheet)
☐Water Meter Data Attached
Total flow:
Gravel, cobbles, highly permeable soil
☐Type II: Sandy Loam,
Fine Sand, Loam
2.0
☐
Other:
☐
Cluster
☐Other (type):
No. of Units:
Total flow:
Test Hole / Soil Borings Used:
☐ YES NO ☐
☐
Type III: Silt, Silt Loam,
Clay Loam, Silty Clay
Loam, Sandy Clay Loam
2.0
Soil Classification Methodology used: ☐ Jar Test
Total Flow for this LW System:
Q
☐
Laboratory:
☐
Other:
☐ Hand Sampling
☐Sieve
☐Type IV: Sandy Clay,
Silty Clay, Clay
5.0
Section 2. Treatment Unit and Pump Design:
1
Primary Treatment
Unit
☐
Septic Tank(s)
No. Septic Tank(s)
Manufacturer:
Series / Model / Certification No.:
Capacity (gallons)
Burial Depth:
2
PUMP
☐Pump Tank
Manufacturer:
Series / Model:
Capacity (gallons)
Burial Depth:
☐Pump
☐Dual Pump
Manufacturer:
Series / Model:
Pump Curve Attch’d:
☐YES NO☐
Effluent Pump:
☐YES NO☐
3
ATS
☐Secondary
☐
Standard
☐Conditional
☐Experimental
☐Required
☐Voluntary
Manufacturer:
Series / Model:
Capacity (gallons)
Burial Depth:
☐Tertiary
☐
Disinfection
☐
UV
☐Ozone
☐
Chlorine
☐Required
☐Voluntary
Manufacturer:
Series / Model:
Notes:
Section 3 Disposal System Design, Components and Calculations
A. Minimum Required absorption area, calculated (Multiply Design Flow (Q) times Application Rate (AR):
Q
X
AR
=
Min. Sq. Ft. Required:
B. Design Components:
☐
Distribution Box
☐
Tee
☐
Drop Box
☐
Alternating Drainfield Valve
☐
Other:
CONVENTIONAL DISPOSAL
☐Pipe & Gravel
Trench Width:
Depth Gravel Below Pipe:
Total Linear Feet:
No. of Trenches:
Max Trench Depth:
Length, each trench:
Trench Spacing (ft):
Proposed Sq. Ft.:
☐Chamber
☐Synthetic Agg.
☐Other:
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.:
☐Seepage Pit
☐Absorption Bed
Dimensions (L x W):
Depth below invert:
Proposed Sq. Ft.:
Max Trench Depth:
Notes:
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.
Alternative Disposal System
Discharging
☐Wisconsin Mound ☐Elevated System ☐Unlined ET Bed
☐Effluent Irrigation
Re-use
☐Sand-Lined Trench
Sand ASTM Specs Attached?
☐ YES NO ☐
☐Bottomless Sand Filters
Sand ASTM Specs Attached?
☐ YES NO ☐
☐LPD ☐LPP ☐Graywater ☐Drip Irrigation
☐Split Flow (complete holding tank section & septic tank & conventional disposal section) ☐Wetland ☐Other (description):
Non- Discharging
☐
Holding
Tank
No. of Tank(s)
Manufacturer:
NM Certification No.:
Capacity:
Burial Depth:
High Water Alarm at 80%?
☐ YES NO ☐
☐Lined ET Bed
Sand ASTM Specs Attached?
☐ YES NO ☐
Liner Material & Thickness (mils):
Dimensions (L x W ) & sq. ft.:
☐Lined Lagoon
Liner Material & Thickness (mils):
Dimensions (L x W ) & sq. ft.:
☐Vault ☐Privy (outhouse) ☐Other (description):
Section 5
Setbacks / Site
Plan &
Attachments
(check those that
apply)
☐
YES NO
☐
1. Does proposed system meet all setbacks required per Table 302.1?
☐ YES NO ☐
2. Site plan attached which shows all structures, LW systems, and wells / waters within 200’ with all setbacks clearly shown?
☐
N/A
☐
YES NO
☐ 3. If ATS or ADS, all requirements under section 403 are submitted, including calculations and drawings?
Supporting Documents Included:
☐Survey ☐Plat ☐Floorplan ☐Warranty Deed ☐Tax Bill ☐Other:
Table 302.1 Minimum setback and clearance requirements
From:
To:
Building
Sewer
Treatment Unit*
Disposal
Field
Seepage
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
or flood
irrigation areas
-- 15 ft. 15 ft. 15 ft.
Seasonal high water table,
bedrock and
other impervious
layers***
-- --
4 ft. to
bottom
of
system
4 ft. to
bottom
of
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.
Table 301.1
Total Design Flow
gpd
Minimum Lot Size
Acres
375 or less
0.75
440
0.88
500
1.00
750
1.50
1125
2.25
1500
3.00
1875
3.75
2000
4.00
Bedrooms, Design Flow, Capacity of Septic Tanks,
combined tables, combines 201P and table 201.2
Single
family
dwelling,
number of
bedrooms
Design
Flow (gpd-
gallons
per day)
Other uses
maximum
fixture
units*
Minimum
septic tank
capacity in
gallons served
1
150
10
750
2
300
12
1000
3
375
12
1000
4
440
15
1200
5
500
20
1500
6
550
20
1500
7
600
27
2000
8
650
27
2000
9
700
27
2000
29
2250
32
2500
35
2750
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Registration New Mexico Environment Department Environmental Health Bureau (State of New Mexico)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document