Onsite Wastewater Disposal Application Form - Health Department - Peoria - Illinois
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4Permit #
____________________________________
Fee: $225.00 • DO NOT SEND CASH
Payable to: Peoria City/County Health Department
o Variance Requested (Completed Variance
Application and $75.00 fee MUST be included.)
Peoria City/County Health Department
Onsite Wastewater Disposal Application
Please mark appropriate spaces & fill in all additional information. Use N/A if not applicable.
Application for:
o New Construction
o Replacement
o Repair or Improvement
Permit Information:
o Owner’s Name:
_________________________________________________________ Phone: ___________________________
Mailing Address: ________________________________________
City: ________________________ ZIP: ________________
Email: ________________________________________________
o Contractor's Name:
_____________________________________________________ Phone: ___________________________
Address: ______________________________________________
City: ________________________ ZIP: ________________
License #: _____________________________________________
Email: _____________________________________________
Property Information:
o Site Address (911):
______________________________________________
Town: ___________________ ZIP ___________
Tax ID/Parcel #: ___________________________________________________
Lot Size: __________ acres
Subdivision:______________________________________
Lot #: ________________ Township: _________________________
Directions to Site from Peoria City/County Health Department (Highway number, Secondary roads, Signs to follow, etc.):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Type of Dwelling:
o Single Family Residential:
Number of Bedrooms: ___________
o Non-Residential System Type: o Restaurant
o School
o Camp
o Church
o Mobile Home Park
o Office Building
o Other: ________________
# of Units
: _________
Design Flow: __________ gallons/day: ______
(i.e. employees, seats, spaces)
Other Information:
Seasonal/Part-Time Use? .............. o Yes ..........o No
Class V Injection Well? ...........o Yes ..........o No
Garbage Grinder? .............................o Yes ..........o No
Basement Plumbing? ..............o Yes ..........o No
Jetted Tubs (>125 gallons)? .............o Yes, ______ gallons ........o No
Discharge to: _________________
Water Softener? ................................o Yes, ______ gallons ........o No
Discharge to: _________________
Hot Tubs? ..........................................o Yes, ______ gallons ........o No
Discharge to: _________________
Water Supply:
o Public Water
o Existing Well
o Proposed Well
o N/A
(if checked, provide last 12 months of meter readings)
Geothermal/
Closed Loop Well:
o New
o Existing
o Proposed
o N/A
form continues…
Peoria City/County Health Department • Environmental Health • 2116 N. Sheridan Rd. • Peoria, IL 61604 • 309/679-6161 •
11/15
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