ds-05 11/08
OSE File Number:
NEW MEXICO OFFICE OF THE STATE ENGINEER
APPLICATION FOR PERMIT
TO ALTER OR REPAIR A DAM AND RESERVOIR
1. OWNER INFORMATION:
I,
of
County of
, State of
, owner of
Dam, hereby make application for the approval of plans
and specifications for the repair of
Dam or reservoir.
If the owner is a corporation, give name and address of president and secretary:
2. LOCATION:
A.
¼
in
or X =
¼
¼ Section:
Township:
Range:
N.M.P.M.
County.
feet, Y =
feet, N.M. State Plane Coordinate System
Zone Datum of
in the
Grant.
B. Latitude in decimal degrees:
Longitude in decimal degrees:
3. HAZARD POTENTIAL CLASSIFICATION:
4. DESCRIPTION OF PROPOSED WORK:
A. Type of dam
B. Description of work contemplated (Use extra sheets or exhibits if necessary.)
OSE File Number:
NEW MEXICO OFFICE OF THE STATE ENGINEER
APPLICATION FOR PERMIT
TO ALTER OR REPAIR A DAM AND RESERVOIR
5. DESCRIPTION OF DEFICIENCIES OF DAM WITH DESIGN REQUIREMENTS FOR DAMS
(19.25.12. 11 NMAC):
6. Work is commenced by
, and to be completed by
7. Engineer
.
8. Contractor
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 and alteration related to 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)
INSTRUCTIONS
Use this form if the properties of the dam or appurtenant structures will not change as a result of the
alteration or 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.
Hit “F1” key for additional instructions for each cell. Cell sizes are limited.
Office of the State Engineer Dam File Number required.
Section 1 Name and address of the representative of the owner making the application. Private owners
must enter their name. Public or corporate owners must enter the name of the official
authorized to make the application. Name of dam must also be entered.
Section 2 Location of dam is required.
Section 3 Hazard potential classification is required. Refer to 19.25.12.10 NMAC.
Section 4 Items A and B are required.
Section 5 Dates of estimated start and completion of work are required.
Section 6 Name of Design Engineer.
Section 7 Name of Contractor selected.
Section 8 Dam Owner’s printed name and notarized signature are required.