Application For Permit To Construct A Private Sewage Disposal System Form - Adams County Health Department
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1
2ADAMS COUNTY HEALTH DEPARTMENT
QUINCY, ILLINOIS
APPLICATION FOR PERMIT TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM
PERMIT NUMBER:________________________ DATE:______________________ PERMIT FEE $150
PD
(office use only)
Name___________________________________________________ Mailing Address_____________________________________
Site Address__________________________________________________________________Lot Size________________________
Subdivision (If applicable)________________________________________________Lot No._______Phone #_________________
Directions to site:____________________________________________________________________________________________
____________________________________________________________________________________________________________
PROPERTY INFORMATION
New Construction (
)
Alteration/Renovation (
)
Public Sewer Available
Yes (
) No (
) Water Supply: Public (
) Private Well (
) Other ( ) Describe _________________
Residential:
Single Family( ) Multi Family ( ) No. of Bedrooms ( ) Permanent ( ) Seasonal ( ) Garbage Disposal ( )
Basement ( )
Basement fixtures ( )
Non-Residential: No. of employees/patrons ___ No. of restrooms ___ No. of Fixtures ____
Design Flow _______total gallons/day
Description:________________________________________________________________________________________________
SOIL INFORMATION
Soil Investigation:
Loading Rates: ______
Soil Percolation Test________ Depth Test Conducted ______________
Average depth to limiting layer ___________
SEPTIC SYSTEM COMPONENTS
Septic Tank:
Capacity ___________
Il. Approval No. ___________________________ New ( ) Existing ( )
Seepage field ( ) Seepage bed ( ) Total square feet _________ Width of trench __________ Depth _________ Length ________
( ) Gravel-less Chamber
Total Square Feet_____________ Total Linear Feet __________ Chamber Size _______________
( ) Gravel-less Pipe: 8” Total Linear ft _____ 10” Total Linear ft _____ Manufacturer_____________________________________
( ) Buried Sandfilter: Total square ft _______ Width of trench _______ Length of trench __________
Chlorinator/contact chamber ( ) Discharges to __________________________________________________________________
( ) Aerobic Treatment Plant: Capacity ______(gpd) Manufacturer______________________________________________________
Location of audio & visual alarms ______________ Discharges to __________________________________________________
( ) Other: Describe ___________________________________________________________________________________________
I certify that the attached information is complete and correct. I understand that I am responsible to maintain this private sewage disposal
system to ensure that it does not cause a nuisance or health hazard. I may, in the future, be required to provide documentation that this
system is being properly maintained as required under the provision of the Illinois Private Sewage Disposal Licensing Act and Code.
Owners Signature ___________________________________________________ Date______________________________________
Permit is hereby granted to construct a private sewage disposal system on the basis of the above information submitted on the
application.
Approved by_______________________________________________________ Date ______________________________________
Everyone/healthprotection/env health/septic permit application/11-09
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