WAYNE COUNTY HEALTH DEPARTMENT, PH. 618 842-5166
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
PRIVATE SEWAGE DISPOSAL SYSTEM
PLAN REVIEW APPLICATION
PERMIT FEE $50.00 DATE:
LOG/PERMIT NUMBER COUNTY
(OFFICE USE ONLY) (OFFICE USE ONLY)
OWNER: TELEPHONE NO:
ADDRESS:
CONTRACTOR: LICENSE NUMBER:
ADDRESS: Telephone No.
NOTE: Work not done by homeowner (must own & occupy personal single family residence) MUST be done by a licensed contractor.
Location- County: City: Street:
Subdivision & Lot # Township Name:
Township: Range: Section #: ¼ Section: Local Identification Information:
Detailed Directions to Site: Highway Number, Secondary Roads, Signs to follow, etc.:
Site Information: Renovation: New System:
Residential Dwelling: Seasonal: Yes Number of Residents: Number of Bedrooms:
Garbage Grinder:Yes Basement: Yes Water Softener: Yes Hot Tub: #Gallons:
Non-Residential: Number 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:
(Attach copy of Soil Data Report to application)
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. Chlorination 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.
e. Seepage Bed Sq. Ft. k. Location of Audio & Visual Alarms
f. Waste Stabilization Pond Length Width Depth
g. Buried Sand Filter/Recirculating Sand filter Sq. Ft. (Garage, Basement, Stairwell, Etc.)
l. Effluent Discharge to:
Width: Length: m.Pump Chamber Size
Other:
1. 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 (including wells on neighboring property if they are near the property line), potable water storage tanks, buildings, lot lines, location of percolation holes, site elevations & ground surface elevations sufficient to determine this elevation of system components & the slope of the ground surface, location of sanitary sewer, if available, within 100 feet of the property, depth of limiting layer and any other extraordinary conditions on the lot.
Checklist:
Lot Size: System Dimensions: Materials Labeled: Water Supply Shown:
System Details:
Pipe Material: ASTM# Setback Distances: H2O line to building sewer: `
Grade: building sewer to discharge : Septic tank/ aerator to well/H2O line:
Discharge leaving property: yes( ) no ( ) BSF Distribution lines # : spacing:
BSF Collection lines # spacing
The Wayne/Hamilton County Health Department does not guarantee trouble-free operation of this sewage treatment and disposal system by the issuance of this approval. The contractor and property owner are responsible for an installation that is in compliance with the Illinois Private
Sewage Disposal Licensing Act and Code. The property owner assumes full responsibility for and nuisance or health hazard that might result
from its use.
I certify that the attached information is complete and correct and that, if approved, the work will conform with the current Private Sewage Disposal Licensing Act and Code.
IMPORTANT NOTICE:
State Agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Public Act 84-760. Disclosure of this information is mandatory.
82-0531 Rev. 9/99