Onsite Wastewater Disposal Application Form - Health Department - Peoria - Illinois Page 2
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1
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4Installation Proposal
Primary Treatment:
Distance to:
nearest well: ______ft.
foundation wall: ______ ft.
property line: ______ft.
water line: ______ ft.
Septic Tank:
o New
o Existing Tank
o Holding Tank
o Other ____________________________________________
Type of Material: ___________________
Tank Capacity: _____________ gallons
Manufacturer __________________________________________________________
IL# _____________________
Depth of Cover: _______ inches
# of Risers _______________________
Aerobic Treatment Plant:
Manufacturer ______________________________________________________
Model: ____________________
Daily Treatment Capacity: _________ gallons per day
Alarm Location: __________________________________
Discharge to: o ⅔ Size Subsurface System o Effluent Reduction o Raised Filter Bed o Other _______________
Secondary Treatment:
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: _________
Subsurface Systems:
Total square feet required:_______________ sq. ft.
Depth of system: ________________ in.
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.
o Seepage Bed:
Width: _______ ft.
Length: ________ ft.
Number of lines: _______
Distance between lines: ________ft.
o Raised Filter Bed:
Mantle width: _________ ft.
Mantle length: ________ ft.
Total square feet of Mantle
: _______sq. ft.
(calculations MUST be attached)
Number of filter beds:: _____________
Following is needed for each bed:
Width ___________ ft..
Length ____________ft.
Square feet of bed: _____________ ft.
Number of vents: _______________
Other Approved System: __________________________________________________________________________
o
________________________________________________________________________________________________________
Surface Discharging Systems:
o Buried Sand Filter:
Width: ___________ ft.
Length: ___________ ft.
Total square feet required: _______________sq. ft.
Number Collection Lines: ________________ ft.
Number Distribution Lines _____________
Number Vents: _____________
Source of Media: _________________________________
Source of Rock: _________________________________________
Other Approved System: __________________________________________________________________________
o
________________________________________________________________________________________________________
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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