Applicant affirms that the information provided in Part B is accurate.
Signature of Applicant or Authorized Representative Date
I certify that the documentation supporting this checklist is complete and accurate:
Signature of Qualified Nutrient Management Planner, other than applicant: ______________________________________
(qualified by 1. NAICC-CPCC, 2. ASA-CCA, 3. ASA-Professional Agronomist, 4. SSSA-Soil Scientist)
Signature of Applicant or Authorized Representative: _______________________________________________________
Professional Engineer’s
Embossed Seal
Print Name of Engineer (include WI License No.) or Certified Agricultural Engineering Practitioner
______________________________________________________________ _________
Signature of Engineer or Practitioner Date
___________________________________________________________________________
Name of Firm and Address
1 Treat multiple lots as one animal lot if runoff from the animals lots drains to the same treatment area or if runoff from the animal lot treatment areas converges or reaches the same surface water within 200 feet of any of those treatment areas.
2 Indicated by a solid or dashed blue line on a 1:24,000 scale USGS topographic map.
3 “Minor alterations” are repairs or improvements that do not result in a substantially altered animal lot. “Minor alterations” may include conservation practices such as runoff diversions, contouring, and planting vegetation.
4 Runoff may be diverted by means of earthen diversions, curbs, walls, gutters, waterways or other practices, as appropriate.
5 Use safe methods to dispose of collected leachate. For example, leachate may be transferred to waste storage structures and then applied to land at agronomic rates.
______________________________________________________________ _________
Signature of Applicant or Authorized Representative Date
Professional Engineer’s
Embossed Seal
Print Name of Engineer (include WI License No.) or Certified Practitioner
_______________________________________________________________ _________
Signature of Engineer or Practitioner Date
________________________________________________________________
Name of Firm and Address
_____________________________
1 Runoff may be diverted by means of earthen diversions, curbs, walls, gutters, waterways or other practices, as appropriate.
2 Use safe methods to dispose of collected leachate. For example, leachate may be transferred to waste storage and then applied to land at agronomic rates.
3 A tile system or curtain drain may be used to intercept lateral groundwater seepage, as necessary, to achieve the required distance to groundwater.
