Form 3400-053 - Land Application Site Request - Dnr Septage Certification
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4State of Wisconsin, DNR
Land Application Site Request
Septage Certification
Form 3400-053 (R 2/06)
Page 1 of 4
PO Box 7921
Madison, WI 53707-7921
Complete this form for each site and submit to the Sludge / Waste Management Specialist at the appropriate Department of Natural Resources service
center for approval evaluation. An approval letter and/or Form 3400-122 must be obtained before sludge can be applied, unless self-approved. See
additional instructions on pages 3 and 4.
Notice: Completion and submission of this form is mandatory under s. 283.55, Wis. Stats., and ch. NR 204 or 214, Wis. Adm. Code, for Municipal Sludge
and Industrial Waste and under s. 281.48, Wis. Stats., and ch. NR 113, Wis. Adm. Code, for septage. Failure to properly complete and submit this form is
a violation of s. 283.91 or s. 281.48, Wis. Stats., and may result in a monetary penalty and/or imprisonment. Personally identifiable information on this form
is not intended to be used for other purpose but may be made available to requesters under Wisconsin's Open Records law ss. 19.32-19.39, Wis. Stats.
Permittee Information
Telephone Number (include area code)
Permittee Name (or Licensed Business if Septage Site)
Address
City
State
ZIP Code
WPDES Permit Number
Septage License Number
WI-00 __ __ __ __ __
__ __ __ __
Waste Information
Waste(s) to be Land Applied
Whey or Permeate
Industrial Sludge
Food Processing Waste
Septage
Municipal Sludge
Paper Mill Sludge
Industrial Wastewater
Other (specify)
Site Information
Soil Map Sheet Number
Instructions:
Outline the exact location of the site on a soils map, a plat map, and a USGS topo map or aerial
photograph. Also, label the site number.
County (indicate only one)
Site Number / Name
(indicate only one)
City
Village
Town of
Field Number
Legal Description
Section
Township
Range
Acreage
N
N
N
N
N
(add additional sheets, if necessary)
Have all requested sites been in agricultural
Site Owner Name
Yes
No
production in the last 2 years?
If no, explain:
Site Farmer Name (if different than owner)
Municipal Sludge Only
The soil test results must be submitted prior to site approval. If you
Name of Entity Applying Waste
need assistance, please contact your DNR Sludge Management
Specialist.
Has this site been self approved?
Yes
No
Compliance With Site Requirements: Have all site criteria, including distance criteria
for separation between the site boundary and waterways, wells, residences, etc.
If yes, DNR Site Self-Approver Number:
as indicated on page 2 of this form been complied with?
Yes
No
Industrial Waste Only
If no, explain:
Proposed Application Rate
(gal/acre or ton/acre)
Season
Per Application
Total
Summer
Comments:
Winter
Year of Application
Signature of Responsible Party
Date Signed
Printed or Typed Name
Title
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