Onsite Wastewater Disposal Application Form - Health Department - Peoria

Effluent Reduction:

Distance to:

nearest well: ______ft.

foundation wall: ______ ft.

property line: ______ft.

water line: ______ ft.

Soil Analysis Results MUST be attached.

Soil Absorption Rate: ___________

Limiting Layer: __________

Depth of Limiting Layer: ________

Water Table: _________

o Chamber System

o Gravel Trench Field

o Gravel-less Pipe

: .......o 8" pipe ..... o 10" pipe

(choose 1)

Manufacturer: ____________________________________

Type/Model/Pipe: _________________________________________

Total linear feet: _______ ft.

Trench width: ________ in.

Number of lines: ________

Distance between lines: ________ft.

Other Approved System: __________________________________________________________________________

________________________________________________________________________________________________________

General Information:

o Chlorine Contact Chamber: .......

o Yes ........ o No

Size: _______ gallons

Discharge to: _______________________

o Pump Chamber: ..........................

o Yes ........ o No

Size: _______ gallons

Alarm Location: ____________________

o Sample Port: ...............................

o Yes ........ o No

Location: _________________________________________________

Other Requirements:

___________________________________________________________________________________________

All Applications Must Have the Following Information Attached:

o A copy of the soil investigation report.

o Labeled plans to scale with distance in feet showing location, size, and type of system in relationship to

the building served. Indicate lot size, building setbacks, measurements for all mandated code setbacks,

source(s) of water, geothermal system, property lines, and buildings. Show site elevations and ground

surface elevations including contours as shown on Peoria County GIS (normally 2 foot elevations).

I certify that I have reviewed the United States Environmental Protection Agency's National

Initials

Pollutant Discharge Elimination (NPDES) General Permit ILG62 and if applicable have been

Required

granted coverage under the permit. Please note if you are covered under the Permit, a copy of your

notice of intent along with proof of date received by USEPA must be submitted along with the application.

The Permit requirements can be found at:

The applicant's signature serves as written acknowledgement that the property owner(s) is/are aware and accept

the responsibility to service and maintain the onsite wastewater treatment system in accordance with the IL

Private Sewage Disposal Licensing Act, the IL Private Sewage Disposal Code, and Chapter 19 Onsite Wastewater

Treatment Systems of the Peoria County Code. If the owner of the site is a developer or contractor, he/she shall

notify the purchaser and Health Department of the transfer of ownership and responsibility for maintenance.

NOTE: If a Variance is requested, a completed Variance Application and $75.00 fee MUST be included.

I certify that the attached information is complete and correct and that installation of said system will conform

with the laws and/or ordinances of Peoria County, Illinois. I accept the responsibility of notifying the Health

Department 48 hours prior to installation to schedule a final inspection of the sewage disposal system

construction PRIOR to backfilling said installation.

Owner/Applicant Signature: ____________________________________

Date: _______________

(required)

Contractor Signature: _________________________________________

Date: _______________

(required)

Peoria City/County Health Department • Environmental Health • 2116 N. Sheridan Rd. • Peoria, IL 61604 • 309/679-6161 •

11/15

Onsite Wastewater Disposal Application Form - Health Department - Peoria - Illinois Page 3

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