ILLINOIS DEPARTMENT OF PUBLIC HEALTH
PRIVATE SEWAGE DISPOSAL SYSTEM
PLAN REVIEW APPLICATION
LOG/PERMIT NUMBER_______________________________COUNTY____________________
                                                            (Office Use Only)                                                                       (Office Use Only)

1. Owner:__________________________________________________Telephone No.:____________________

Address:_____________________________________________________________________________________

2. Contractor:_______________________________License No.:_______________Phone No.:_______________

Address:___________________________________________________________________________________________________________

NOTE: Work not done by homeowner (must own & occupy personal single family residence) must be done by a licensed contractor

3.Location-County:_________________________City:_______________________Street:____________________________

Subdivision & Lot #:_____________________________________TownshipName:_________________________________________

Township:__________Range:______Section#:_______1/4 Section:______Local Identification Information_____________

4. Detailed Directions to Site: Highway Number, Secondary Roads, Signs to follow, Etc.;__________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

5. Site information Renovation:_____ New System:_____

Residential Dwelling:_____, Seasonal: Yes_____ No. of Residents:_____ No. of Bedrooms:_____

Garbage Grinder: Yes_____ No_____ Basement: Yes_____ No_____ Water Softener: Yes_____ No_____ Hot Tub: #Gallons__________

Non-Residential:_____ No. of Employees:______ Design Flow:________ Other Wastewater Generators:_______________________

Water Supply: Private Well: _____, Semi-Private Well: _____, Non-Community: _____, Municipal:_______

Percolation Tests: Date(s):____________________Conducted by:____________________________________

Hole No.1: Depth_____,_____min./6" Hole No.2: Depth______,______min/6"Hole No.3: Depth_____,_____min/6"

Average min./6" Fall:__________________ (Rerun or use highest value if difference is greater than 30 minutes)

Depth of Limiting Layer:_______________ Soil Type:_________________________________________________

Soil Scientist Data: Name of Soil Investigator:________________________________________________________

6. Proposed Private Sewage Disposal System:           Gallons To Be Treated Per Day:____________________________

a. Septic Tank Size______ Gallons, Illinois #________________ h. Wisconsin Mound Basal Area ______ Sq. Ft.

b. Subsurface Seepage Field/Bedroom _______ Sq. Ft. i. Chlorinating Tank _________ Gallons (If Required)

Total Subsurface Seepage Field _____ Sq. Ft., Lin. Ft. _____, Width_____ j. Aerobic Treatment Plant:___________________________

c. Gravel-less Seepage Field: 8":_____Lin. Ft. _____. 10"_____Lin. Ft. Manufacturer & Model:____________________

d. Chamber System: Manufacturer:__________________________ Treatment Capacity: _______________Gallons per day

Sq. Ft. per Lin. Ft.,______________ Total Lin. Ft.______________ k. Location of Audio & Visual Alarms___________

e. Seepage Bed __________ Sq. Ft.                                                                   ______________________________________________

f. Waste Stabilization Pond _____ Length _____ Width _____ Depth_____                       (Garage, Basement, Stairwell, Etc.)

g. Buried Sand Filter/Recirculating Sand Filter __________ Sq. Ft. l. Effluent Discharge to:___________________________

Width: _______________, Length:_______________ m. Pump Chamber Size _____________________________

Other _________________________________________________________________________________________________________________

PRIVATE SEWAGE DISPOSAL SYSTEM
PLAN REVIEW APPLICATION

7. Lot diagram and sewage system plan.

Furnish plans or draw to scale the proposed construction indicating lot size with dimension showing the system, type of system, to be constructed, the dimensions of the system to be installed showing type of material, utilities, distances to water lines, water wells, potable water storage tanks, buildings, lot lines, location of percolation holes, proposed elevation of the system components, slope, depth of limiting layer, and any other extraordinary conditions on the lot.

N

+

1"=__________

Depth of Cover Inches____________Width in Inches__________

Elevations of the System Components

Benchmark & Elevation:_____________________________

Elevation to Invert of Building Drain:___________________

Cover Material_______                                                               Elevation to Invert of Tank Outlet:_______________________

Lowest Elevation of Ground Surface over Field_______________

Inches_____________                                                                Highest Elevation of Ground Surface over Field____________

Length of Building Sewer (House to Tank)____________________

Inches_____________                                                                 Extraordinary Condition Shown:_______________________

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