NEW MEXICO OFFICE OF THE STATE ENGINEER
APPLICATION FOR PERMIT
TO REPAIR A DAM
PERMIT NUMBER D- ______
(Provided by NM OSE)
OSE FILE# D-
1.NAME OF DAM:
2.DAM OWNER:
Name: Work Phone:
Title: Home Phone:
Address: Mobile Phone:
City:State: Zip:
If the owner is a corporation, give name and address of president and secretary:
Owner Address: Corporation:
Phone: President:
Secretary:
Phone:
3.PURPOSE OF DAM:
4.HAZARD POTENTIAL CLASSIFICATION:
5.DESCRIPTION OF PROPOSED WORK:
A.Type of dam ______
B.Description of deficiencies of dam to be addressed and applicable design requirements (19.25.12.11 NMAC):
C.Description of work contemplated (Use extra sheets, construction plans and specifications or exhibits as necessary to describe.):
6.Work is to be commenced by ______(date), and to be completed by ______(date).
7.Dam will be repaired under the supervision of:
______Engineer License No.______
8. Contractor ______License No.______
9. ACKNOWLEDGEMENT FOR THE DAM OWNER:
I, ______affirm that the foregoing statements are true to the best of my knowledge and belief. I fully understand the repair proposed for this dam and the responsibility and liability related to dam ownership.
Signed: ______Date: ______
Subscribed and sworn to before me this ______day of______, 20__
Notary Public: ______
My commission expires: ______(SEAL)
FEES & APPLICATION SUBMITTAL
Use this form if the properties of the dam or appurtenant structures will not change [asdefined in 19.25.12 NMAC] as a result of the repair. This form shall be filed with original signatures and accompanied by construction drawings, specifications, design report, etc. and filing fee of $25.00 for the application and plan review fee of $2.00 per $1000 of construction cost for dam and appurtenances. Owners repairing a dam to address a dam safety deficiency may request a waiver of the plan review fee. This form and supporting documentation shall be delivered to the attention of the OSE Dam Safety Bureau, P.O. Box 25102, Santa Fe, New Mexico.
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