HomeMy WebLinkAbout040-1056-10-000 •, ayo 105n - J - 000
State of Wisconsin SEPTAGE J/ A A 7
Department of Natural Resources REQUEST FOR FIELD APPROVAL
Form 3400 -133 10 -87
Completion and submission of this document with appropriate Date Sent to DNR
support information is mandatory under s. 146.20, Wis. Stats.,
and Chapter NR 113, Wis. Adm. Code. Failure to properly [X] One)
complete and submit this form while using a site for land Low Use Dormant Field
a
disposal of septage is a violation of s. 146.20 and C ter Locptiog of Field; County d Township ,Q
NR 113 and may result in a monetary penalty. ST • � 0 , 0/
a esc ' ection Township Rig n e
/ T / 7
Name and Address of DNR District Office Estimated Acreage n
Fp /o
DNR License Number
�3 %,
Submitted Information (Check [X] boxes if sent)
®1 copy of Request for Field Approval
S -yDv (Form 3400 -133)
L— O 3 copies of a Site Location Map
Name, Name of Firm and Address of Licensed Disposer Pnd
E] 3 copies of a Soil Information Map
Johnson Sanitation ❑ 3 copies of the Soil Investigation Data (only if
no Soil Information Map is available)
W5990 570th Avenue
Ellsworth Wf 54011 -5100 ❑ 3 copies of a completed WDNR Agricultural Field
Operations Form (Form 3400 -102)
L ❑ 3 copies of other information
DO NOT COMPLETE THE BOTTOM PORTION -DNR USE ONLY: SEPTAGE DISPOSAL FIELD APPROVAL /DENIAL
Action by WDNR (See checked and initialed box for Date Received
d�G /Y t j q?
action taken) �
Field Legal Descripttion Secti Township Range Jj
❑ Denied due to insufficient information being submitted �J V ) SW L / 7 N 4 ?
(See circled areas above as indication of missing Approximate Fl Id Size (Ac) DNR Field No.
information) 7 0 G I 4_ .
B y - --
❑ Special condition(s) of approval
By
Approved ] based on submitted information /I �
By - [ —"-�-_ (V J J t I
❑ Denied based on submitted information ,
By - -__ —_ M t 1o4
❑ Approved conditionally until inspected (by WDNR staff)-
B e
y
❑ Denied until inspected (by WDNR staff)
By - - - - -- ❑ Only the area outlined by red on the Site, Location
Map is approved
By
WDNR Reviewer's Name
❑ Approved based on WDNR inspection — RI
By _ Reviewer's Telephone Number
❑ Denied based on WDNR inspection (71 ) q' Z ? qj
B - -- _ Date of Action Q
i
State of Wisconsin SEPTAGE
Department of Natural Resources AGRICULTURAL FIELD OPERATIONS
Form 3400 -102 Rev. 3 -88
Complete this form for each field and send to the Completion and submission of this document with
appropriate Department of Natural Resources district appropriate support information is mandatory under
office for evaluation seven days before the field is s. 146.20, Wis. Stats., and ch. NR 113, Wis. Adm.
to be used for landspreading of septage. Code. Failure to properly complete and submit this form
while using a site for land disposal of septage is a
Additional copies of this form are available upon violation of s. 146.20 and ch. NR 113 and may result
request. in a monetary penalty.
Name of Licensed Business
Johnson's Sanitation
Street or Route W5990 570M A County and Township Location of Field
Ellsworth Al 54011-5100 S' - ( f o % Z' a
City, State, Zip Code Le al e c i tion Section r Ran ge �� l / A j & .
Telephone Number Estimated Acreage
(i ') o7 5 S'l O
AGRICULTURAL FIELDS
1. Name of Field Owner 8. Minimum distance to a private or noncommunity well
L GT
2. Naafie of Field Farmer (if different than owner) Feet (if less than 1/2 mile)
9. Minimum distance to a surface water, sink hole or
3. Are local permits required? [:]Yes No wetland
Feet (If less than 112 mile)
If yes, by whom?
10. Minimum distance to a dry run or ditch
Feet (if less than 1/2 mile)
4. How is access to the field limited? 11. Estimated depth to groundwater
R] Fences ❑ Remote location Feet
❑ Warning signs ❑ Other (describe)
12. Estimated depth to bedrock
5. Has the field been used in the past for septage or sludge
disposal? Feet
❑ Yes R No
13. Maximum slope
P
A. If yes, please Identify by whom
°k
14. What type of land use. Is adjacent to disposal field
(X all appropriate)
[]Residential Agricultural [:]Mining Operation
❑Commercial ❑ Forest ❑ Recreational
❑ Industrial ❑ Landfill ❑ Other
B. When was septage or POTW 15. Land use of disposal field
sludge last spread on field? Agricultural [] Other
(Month and Year)
❑
C. How many years has the field Forest
been used for disposal? If agricultural, what crop is being grown or will be
6. Minimum distance to a residence, business or grown within eight months?
recreational area If Q dAl
Feet (if less than 1/2 mile)
7. Mininum distance to a community water supply well 16. Estimate of amount of septage spread annually
Feet (if less than 1/2 mile) G Gallons per acre
Sig ure
Date SIgne ,
Qr
I
EAST -W T. 28 N - R.19
W. 15
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®/99/ Ro for MaPPu6 a mac. P/ERCE COUNTY Si crow county O
500 600 700 800 900
BALDWIN 54002 n Will Move You..
Si g .
ERICKSOIV Junction 1 -94 & Highway 63 Our
OM HUDSON 54016
FREED For sale
Coulee Rood EdinaRealfy Edina Realty
k..
SON 54016 Imo.
219 Second Street 388 8236
Fdia RnRf h . MetroplRn i1rrW C•Pa.Rw c°wMq.
NEW RICHMOND 54017 Prescott: 262 -3500
455 South Knowles Avenue New Richmond: 246 -5059 386 -8236
St. Croix Falls: 483 -3833
V-fZ WANT TO BE YOUR CONVENIENCE STORE TWIN CITIES LINE: 436 -7072 • 700 - 2nd STREET, HUDSON
+ .fir 6 71��
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