APPLICATION FOR PERMIT TO CONSTRUCTION AND …



OSE FILE# D- FORMTEXT ???? 1.NAME OF DAM: FORMTEXT ?????2.DAM OWNER: FORMTEXT ?????Name: FORMTEXT ?????Work Phone: FORMTEXT ?????Title: FORMTEXT ?????Home Phone: FORMTEXT ?????Address: FORMTEXT ????? Mobile Phone: FORMTEXT ????? FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ????? Zip: FORMTEXT ?????If the owner is a corporation, give name and address of president and secretary:Owner Address: FORMTEXT ?????Corporation: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Phone: FORMTEXT ????? President: FORMTEXT ????? Secretary: FORMTEXT ????? Phone: FORMTEXT ????? 3.PURPOSE OF DAM: FORMTEXT ?????4.HAZARD POTENTIAL CLASSIFICATION: FORMTEXT ?????5.LOCATION: A. FORMTEXT ??1/4 FORMTEXT ??1/4 FORMTEXT ??1/4 Section: FORMTEXT ?? Township: FORMTEXT ???? Range: FORMTEXT ???? N.M.P.M.in FORMTEXT ????? County. or X = FORMTEXT ????? feet, Y = FORMTEXT ????? feet, N.M. State Plane Coordinate System FORMTEXT ????? Zone Datum of FORMTEXT ????? in the FORMTEXT ????? Grant. B.Latitude in decimal degrees: FORMTEXT ????? Longitude in decimal degrees: FORMTEXT ????? C.On land owned by: FORMTEXT ?????D.Source of Water Supply:a. Name of Surface Watercourse: FORMTEXT ????? Tributary of FORMTEXT ?????b. Name of Groundwater Basin: FORMTEXT ?????c. Name of Ditch or Spring (Off Channel Dams): FORMTEXT ?????E.Distance to the nearest downstream population at risk (river miles): FORMTEXT ?????6.DRAINAGE AREA, PRECIPITATION DATA AND SPILLWAY DESIGN FLOOD RESULTS:A.Drainage area: FORMTEXT ????? acres or FORMTEXT ????? square milesB.100-year precipitation, FORMTEXT ????? hour duration: FORMTEXT ????? inches (governing storm for low hazard dams) Probable maximum precipitation (PMP), FORMTEXT ?????-hour storm: FORMTEXT ????? inches (governing storm for high and significant hazard dams)Peak runoff into the reservoir from FORMTEXT ?????% of the FORMTEXT ?????-hour governing storm: FORMTEXT ????? cfsVolume of runoff into the reservoir from FORMTEXT ?????% of the FORMTEXT ?????-hour governing storm: FORMTEXT ????? acre-feetMaximum water surface elevation in the reservoir from FORMTEXT ?????% of the FORMTEXT ?????-hour governing storm: FORMTEXT ????? ft.Routed peak outflow from the reservoir from FORMTEXT ?????% of the FORMTEXT ?????-hour governing storm: FORMTEXT ????? cfs7.PROPERTIES OF DAM AND RESERVOIR: A.Length of Dam: FORMTEXT ????? feetB.Crest width: FORMTEXT ????? feetC.Base width: FORMTEXT ????? feetD.Dam height: FORMTEXT ????? feetE.Structural height: FORMTEXT ????? feetF.Elevation of the dam crest: FORMTEXT ????? feet (Mean Sea Level)G.Slope of upstream face: FORMTEXT ????? horizontal to 1 verticalH.Slope of downstream face: FORMTEXT ????? horizontal to 1 verticalI.Volume of dam: FORMTEXT ????? cubic yardsJ.Type of dam: FORMTEXT ?????K.Dead storage capacity: FORMTEXT ????? acre-feetL.Reservoir storage capacity: FORMTEXT ????? acre-feetM.Maximum storage capacity: FORMTEXT ????? acre-feetN.Reservoir elevation during Spillway Design Flood: FORMTEXT ????? feetO.Reservoir surface area at reservoir storage capacity: FORMTEXT ????? acresP.Stage/Area/Storage capacity (elevations at the outlet invert, spillway and dam crest plus others):Elevation or depth Area of WaterStorage CapacityComment above outlet (Feet)Surface, (Acres)(Acre Feet) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8.PROPERTIES OF OUTLET CONDUIT:A.Outlet conduit is: FORMTEXT ????? (give size and material)B.Length of conduit: FORMTEXT ????? feetC.Slope of conduit: FORMTEXT ????? percentD.Roughness coefficient: FORMTEXT ????? (specify calculation method)E.Maximum discharge capacity (with reservoir at dam crest elevation): FORMTEXT ????? cubic feet/secondF.Elevation of upstream end of the invert of the outlet conduit: FORMTEXT ????? feetG.Size, type and number of gates: FORMTEXT ?????H.Time to empty the reservoir when reservoir is at spillway crest elevation: FORMTEXT ????? hours or FORMTEXT ????? days9.PROPERTIES OF SPILLWAY:A. Spillway is: FORMTEXT ????? (give type and material)B.Location with respect to dam: FORMTEXT ?????C.Spillway crest elevation: FORMTEXT ????? feetD.Freeboard: FORMTEXT ????? feet E.Discharge coefficients: FORMTEXT ????? (dependent on type)F.Effective length: FORMTEXT ????? feetG.Discharge capacity (with reservoir at the Spillway Design Flood elevation): FORMTEXT ????? cubic feet/secondMaximum discharge capacity (with reservoir at the dam crest elevation): FORMTEXT ????? cubic feet/secondResidual freeboard (with reservoir at Spillway Design Flood): FORMTEXT ????? feet10.ADDITIONAL STATEMENTS OR EXPLANATIONS: FORMTEXT ?????11.CONSTRUCTION DATES:Estimated date to begin construction: FORMTEXT ?????Estimated date to complete construction: FORMTEXT ?????12.Dam will be constructed under the supervision of: FORMTEXT ????? FORMTEXT ?????EngineerLicense No.13.ACKNOWLEDGEMENT FOR THE DAM OWNERI, FORMTEXT ????? affirm that the foregoing statements are true to the best of my knowledge and belief. I fully understand the responsibility and liability related to dam ownership._______________________________________(Signature)(Date)Subscribed and sworn to before me this _______ day of __________________, 20___._______________________________________Notary PublicMy commission expires __________________ (SEAL)FEES & APPLICATION SUBMITTALThis 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. 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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