Form 3400-053 - Land Application Site Request - Dnr Septage Certification Page 2
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4Land Application Site Request
Form 3400-053 (R 2/06)
Page 2 of 4
If any of the applicable separation distances shown below are not complied with, select the "No" box under Compliance With Site Requirements on page 1
of this form and provide an explanation in the space provided (or attach sheet if necessary).
Existing Cover Crop
Tree Plantation
Pasture
Permanent Hayland
Other (specify)
Cultivated Cropland
Has the site been used or is it currently being used for the landspreading of non-agricultural waste?
Yes
No
If yes, select type(s) of waste, and note in the comments section on the front of this form.
Holding Tank / Septic
Combined Waste
Whey or Permeate
Municipal Sludge
Industrial Sludge
Food Processing Waste
Paper Mill Sludge
Industrial Waste
Other (specify)
What type of land use is adjacent to site? (select all appropriate)
Residential
Commercial
Industrial
Agricultural
Forest
Landfill
Mining Operation
Recreational
Other (specify)
The separation distance between the ground surface and bedrock or groundwater is greater than:
36 inches
18 inches
Industrial Sludge and Waste Only
Criteria for Industrial Sludge or Waste Applied to Land
Site Criteria
Surface
Incorporation
Injection
Distance to public water supply
1000 ft.
1000 ft.
1000 ft.
Distance to private water supply
250 ft.
250 ft.
250 ft.
Distance to residence
500 ft.
500 ft.
500 ft.
Distance with written permission
500 ft.
200 ft.
200 ft.
Distance to any surface water or dry run
200 ft.
50 ft.
50 ft.
Distance to any surface water or dry run with vegetative buffer
100 ft.
50 ft.
50 ft.
Municipal Sludge / Septage Only
Criteria for Non-Eq Municipal Sludge / Septage Applied to Land
Site Criteria
Surface
Incorporation
Injection
Depth to bedrock
3 ft.
3 ft.
3 ft.
Depth to high groundwater
3 ft.
3 ft.
3 ft.
Allowable slopes
0–6 %
0–12 %
0–12 %
Distance to wells
Community water supply or school
1000 ft.
1000 ft.
1000 ft.
Other
250 ft.
250 ft.
250 ft.
Minimum distance to residence, business or recreation area
500 ft.
200 ft.
200 ft.
Minimum distance to residence or business with permission
250 ft.
100 ft.
100 ft.
Distance to rural schools and health care facilities
1000 ft.
1000 ft.
500 ft.
Distance to property line
50 ft.
25 ft.
25 ft.
Minimum distance to streams, lakes, ponds, wetlands or channelized waterways connected to a stream, lake, pond or wetland
Slope 0 to < 6
200 ft.
150 ft.
100 ft.
Slope 6 to < 12
Not Allowed
200 ft.
150 ft.
Minimum distance to grass waterways, or dry run with a 50 foot range grass strip.
Slope 0 to < 6
100 ft.
50 ft.
25 ft.
Slope 0 to < 12
Not Allowed
100 ft.
50 ft.
Soil permeability range (in/hr)
0.2–6.0
0–6.0
0–6.0
Note:
The Department will not determine whether the requested sites are in government sponsored agricultural programs (i.e., CRP, ACR, etc.), or
whether they are subject to any local ordinances. The permittee should contact the appropriate government agency to determine whether any
additional restrictions or penalties apply.
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