Boone County Health Department

Permit #:Confirmation #:

New # of Bedrooms: Public

Repair Private

Tank Only # of Employees:

Gallons per day:

Address: Property Owner:

City/Zip Code: Mailing Address:

Subdivision: City/Zip:

Lot #: Phone #:

Parcel #: Email:

Applicant: Contractor:

Address: Address:

City/Zip Code: City/Zip Code:

Phone #: Phone #:

Email: Email:

State License: yes no #:

County License: yes no

Scale: Filter Brand:

Soil Bores Used: Filter Size: Pump

Estimated Gallons: Distribution Box: yes no Even Dosing

Tank Brand: Low Pressure

Tank Gallons: Trench System N/A

IL ID#: Rock & Pipe Field Distribution

ATU Serial #: Chamber Serial

Loading Rate: EZFlow Level

Surface Area: Other Gravelless Combination

Linear Feet: Other:

Tank Distribution

ResidentialType of Permit

Septic Permit Application

Septic Plan Information

Property Information

Application & Contractor Information

Commerical

Water Supply

Boone CountyHealth Department1204 Logan Avenue, Belvidere, Illinois 61008

Main Office 815.544.2951 Clinic 815.544.9730 Fax 815.544.2050www.boonehealth.org

MIN. TANK _____________ / _____________ _______________g/day ÷ ____________g/ft2 /day = ______________sq. ftW/ GARBAGE DISP / NO GARBAGE DISP (EST. WASTE STREAM) (EST. LOAD RATE) (MIN. TRENCH AREA)

SURFACE AREA REQUIRED _______________________ LINEAL FEET REQUIRED _______________________

Conventional 260.00$ Revised Plan Review 75.00$

Mechanical 340.00$ Unlicensed Installer 175.00$

Tank Only 220.00$ Installer Education 80.00$

Additional Lines 15.00$ Homeowner Install 175.00$

Site Verification 125.00$ 175.00$

Soil Bores Report Plan Checklist

Wastestream Information Sheet Elevations Sheet

Owner Sign Off - Maintenance Agreement ATU Operator Permit

Proposed Site Plan Alteration Agreement

Permit Receipt #:

Revised Plan Review Receipt #:

Receipt #:

Proposed Septic System:

Approved Date:

Rejected Date:

Revised Plan Approved Date:

Revised Plan Rejected Date:

County Building Department Property Owner

Assessor's Office Contractor

Com Ed Noitification Township Supervisor

*** OFFICIAL USE ONLY ***

Unlicensed Installer

Inspection

Type of Permit

Other:

Plan Approval & Status

Notification

Other:

Other:

Date:

Required Documentation

Payment

Date:

Date:

Final Approval Stamp Here:

Total Amount: $

V:\Env Programs\private sewage\Forms-Lists\admin forms\Wastestream and Homeowner Install Signoff_feb2020.docx

WASTESTREAM INFORMATION SHEET

Property Address: __________________________________________________________________________

□ Residential *

Number of bedrooms: □ 2 bedrooms □ 3 bedrooms □ 4 bedrooms □5 bedrooms □ Other: ___________

Garbage disposal: □ Yes, there will be a garbage disposal installed

□ No, there will not be a garbage disposal installed

Water Softener: □ NSF Standard 44 (high efficiency) unit is/will be installed. No change in sizing of septic

field will be required and the discharge will be connected indirectly to the main building

drain.

□ The water softener is/will not be a high efficiency unit. The septic field will be increased

in size to accommodate the discharge or the softener unit will discharge to a separate field

sized to accommodate said discharge. If discharging to the main septic system, the discharge

line will bypass the septic tank.

□ No water softener will be installed (for the life of the septic system).

Hot tub/Jacuzzi: □ Yes, there will be a hot tub/jacuzzi or similar fixture (of greater than 100 gallons)

(draining to the Volume:___________ gallons

septic system) □ No, there will not be a hot tub/jacuzzi or similar fixture (of greater than 100 gallons)

□ Commercial/Other

Type of establishment: ______________________________________________________________________

Hours of operation: ____Hours/day ____Days/week

Number and type of employees: □___Full time □___Part time

Number and type of fixtures: □ #___Toilets □ #___Urinals □ #___Sinks □ #___Showers □ #___Washing machines

Water Softener: □ NSF Standard 44 (high efficiency) unit will be installed. No change in sizing of septic field

will be required and the discharge will be connected indirectly to the main building drain.

□ The water softener will not be a high efficiency unit. The septic field will be increased in

size to accommodate the discharge or the softener unit will discharge to a separate field sized

to accommodate said discharge. If discharging to the main septic system, the discharge line

will bypass the septic tank.

□ No water softener will be installed (for the life of the septic system).

Estimated number of customers or residents per day: ________

Estimated square footage of floor area (shopping center): ________

Number of beds (hospitals/hotels) or spaces (mobile home parks or campgrounds): _____

Restaurants: □ No bar & Cocktail □ With bar & Cocktail □ Number of meals served each day: ______

Other notes (ex. chemical disposal): ________________________________________________

_________________________________________ ___________________

Property Owner Signature Date

*NOTE: IF THE SEPTIC IS FOR A SINGLE FAMILY RESIDENCE & IS GOING TO BE INSTALLED BY

THE HOMEOWNER, PLEASE SIGN ON THE BACK OF THIS FORM.

The mission of the Boone County Health Department is to serve our community by

preventing the spread of disease, promoting optimal wellness & protecting the public’s health.

Boone County Health Department

1204 Logan Avenue, Belvidere, Illinois 61008

Main Office 815.544.2951 Clinic 815.544.9730 Fax 815.544.2050 www.boonehealth.org

V:\Env Programs\private sewage\Forms-Lists\admin forms\Wastestream and Homeowner Install Signoff_feb2020.docx

NOTICE FOR HOMEOWNER INSTALLATIONS

I, , the property owner of ______________________________,

Name Property Address

plan to install the septic system at this property as allowed by the following county code.

Sec. 66-28. License requirements.

(a) On and after the effective date of the ordinance from which this article is derived, no person, except for a private

sewage disposal system contractor licensed by the health authority, may construct or alter a private sewage disposal

system. Resident owners or intended resident owners who can demonstrate that they are able to perform the installation

or alteration in conformance with this chapter may install or alter a system for their own single-family residence,

provided such resident owner or intended resident owner pays the applicable unlicensed installer permit fee and complies

with two additional mandatory inspections at times as set forth by the health authority.

I understand that, as the property owner, I am assuming the role and responsibility of the licensed septic system contractor

for this installation. The physical installation of the septic system and its components may not be done by anyone other

than the actual single family resident property owner/s or a licensed septic installer. I understand that I may NOT hire an

unlicensed installer, such as another family member personal friend, etc. to install the septic system. I further understand

that Homeowner Installations require two additional compliance inspections, the cost of which adds $175.00 to the permit

fee. The total of 3 compliance inspections shall consist of:

1) inspection of tank placement

2) inspection of first installed line

3) final inspection of all lines/field

Before each of these inspections a 48 Hour Notice must be given to Boone County Health Department for scheduling

purposes. There is also an optional homeowner septic system installation education available for $80.00 / hour.

I understand and concur that I am assuming the role of a licensed septic system contractor for this installation. I must be

present during all of the installation construction. I agree to hold myself responsible for compliance with any and all

applicable local and state regulations. Failure to abide by this agreement will invoke legal action according to Sec. 66-30

of the Boone County Sewers and Sewage Disposal Code.

____________________________________ _______________________

Property Owner Signature Date





Main Office 815.544.2951 Clinic 815.544.9730 Fax 815.544.2050 www.boonehealth.org

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MAINTENANCE AGREEMENT FOR PRIVATE SEWAGE DISPOSAL SYSTEMS

As a condition of permit application approval for any septic system being installed, repaired, or altered after January 1,

2014, Illinois Department of Public Health requires that property owners acknowledge they are aware of and accept

responsibility for servicing and maintaining their private sewage disposal system. [Illinois Department of Public Health

Private Sewage Disposal Code Sec. 905.20(q)]

You as the property or sewage disposal system owner shall maintain all maintenance records on the form provided. These

records must be transferred from owner to owner and shall be kept for the life of the system.

Septic tanks serving residential or non-residential properties shall be evaluated within three years of the date of

installation of the system. The system can be evaluated by any of the following:

1. Homeowner

2. Private Sewage Disposal System Installation Contractor

3. Licensed Environmental Health Practitioner

4. Illinois Licensed Professional Engineer

5. Representative of the IL Department of Public Health (“Department”)

6. Agent of the Department or Local Health Department (LHD)

The evaluation shall determine whether the tanks and all of the compartments of the private sewage disposal system have

layers of scum and settled solids greater than 33% of the liquid capacity of the tank. If the initial evaluation 3 years after

installation reveal >33% scum/solids, the tanks and compartments shall be pumped out and maintenance shall be

performed as soon as possible. After the first evaluation, the system shall be evaluated a minimum of once every 5 years

if residential and every 3 years if non-residential.

Alternative sewage disposal systems shall be maintained in accordance with the manufacturer’s specifications or based on

a maintenance interval approved by Boone County Health Department.

Failure to properly operate, maintain and have routine service conducted on a private sewage disposal system is a

violation of the IL Private Sewage Disposal Licensing Act & Code.

I/we hereby agree that I/we acknowledge and accept the responsibility to service and maintain the private sewage disposal

system at the property address as outlined below and retain all related records. I understand that this signed form must be

returned to the Boone County Health Department as a condition of septic permit issuance.

Signed: Date:

Property Address:

Property Parcel Identification Number (PIN):

City: Zip Code:




1204 Logan Avenue, Belvidere, Illinois 61008 Main Office 815.544.2951 Clinic 815.544.9730 Fax 815.544.2050

www.boonehealth.org

V:\Env Programs\private sewage\Forms-Lists\admin forms\Maintenance agreement for private sewage disposal systems PHAB rev

2017_05_19.docm

Septic Maintenance Records

Property Address:

Date Service Provider Scum/Settled Solids

Action Taken: Pumped, Baffle Checked, etc. <33% >33%

V:\Env Programs\private sewage\Forms-Lists\admin forms\ATU Owner signoff REV March 2018.docx

AGREEMENT FOR ATU REDUCTION & OPERATOR’S PERMIT

I understand that my septic installer has submitted a proposal for a septic system to be installed

at the following address: ________________________________________, which includes a

non-conventional mechanical system (i.e. ATU - Aerobic Treatment Unit). This type of system

utilizes a reduction in lineal feet of trench as allowed in State Code. Boone County Code also

allows this reduction, with some additional requirements. The property owner of any system that

utilizes a reduction in field lines is required to have a septic system operator’s permit, which will

be issued by our office. Listed below are the requirements for this system type.

ATU OPERATOR’S PERMIT

The operator’s permit shall be renewed every year (for the life of the system) upon

payment of the renewal fee and verification of satisfactory system performance for the

previous year. Satisfactory performance shall consist of the following:

Written statement from a state licensed system maintenance contractor showing

that the system is in compliance with the maintenance requirements of the

manufacturer. (maintenance must be done every 6 months)

No record of complaint or non-compliance regarding private sewage disposal for

this permit remains outstanding at the Health Department.

Annually, after we have received the verification and fee, we will send an Operator's Permit to

you. You will be reminded to renew approximately one month prior to permit expiration.

I understand that failure to renew the operator’s permit or meet all of the requirements for

renewal may result in legal action and/or condemnation of the residence. I also understand

that the Boone County Health Department must be in receipt of this form before a septic

installation permit will be issued.

__________________________________ ______________________

Signature of Property Owner Date





Main Office 815.544.2951 Clinic 815.544.9730 Fax 815.544.2050

www.boonehealth.org

V:\Env Programs\private sewage\Forms-Lists\admin forms\septic alteration agreement_feb2020.docx

AGREEMENT FOR SEPTIC ALTERATIONS

ON EXISTING SEPTIC SYSTEMS

Septic alterations may be necessary in certain cases where a home addition, pool, or other

structure is proposed that encroaches on the area where the existing septic is located or requires

additional lines be added to accommodate additional waste stream. Additional septic lines may

have to be added to the existing field or parts of the existing septic lines may have to be

abandoned and added in a different location on the property.

In any cases where the septic lines must be altered, the homeowner must agree that once the

septic permit is issued and approval is given to the Building Department, that they will complete

the required septic alterations before the expiration of the septic permit. This agreement allows

the property owner to apply for the Building Permit immediately after our approval and issuance

of the septic permit, so that building and construction may start.

As the property owner, I agree to complete the required alterations on my septic system before

the expiration of the septic permit. I understand that failure to do so may result in legal action

being taken by the Boone County Department of Public Health.

____________________________________ ______________________

Signature of Property Owner Date






www.boonehealth.org

Permit application fee must accompany septic plan. The plan will be reviewed and

approved or disapproved within 7 working days and you will be notified by phone. If

approved, a septic permit will be mailed. If disapproved, a written response and

explanation will be mailed.

SEPTIC PLAN CHECKLIST

ADDRESS: _______________________________________________________

CONVENTIONAL SOIL PLANS SHOWS ALL OF THE FOLLOWING:

(Check each box to verify the requirements of the plan have been provided)

Lot dimensions

North orientation

Suitable soils area

Contours

Length of lines/size of tank/approved filter make, size and location

Number of bedrooms in home

All field tile issues (if applicable)

All house/buildings, driveways, pools, easements, drainage areas, etc., which may impact

the septic system or its orientation

Site plan and septic plan are both drawn to an approved scale and the scale is indicated

Existing grade elevations from on-site investigation on at least 4 corners of septic field &

are relative to system profile elevations on the completed profile elevation form

Elevations are consistent throughout the system profile information form

Variance requests must be submitted in writing by the septic contractor and include

acknowledgement from the homeowner

NON-CONVENTIONAL SOIL PLANS MUST ALSO SUBMIT THE FOLLOWING: Aerobic treatment unit specifications, i.e.: make/model

Ground surface contours on at least 5 ft. intervals

Soil bores located on plan

Soil bore information, including limitation types & elevations

REPAIR PLANS MUST ALSO CHECK THE FOLLOWING:

Include the location, depth and elevation detail of the old septic tank and field

As the contractor, I confirm that the information checked above and as presented on the plan are

accurate representations of on-site observations. In addition, I have verified that municipal sewer

is more than 200 ft. from this property. Note: Plan will not be approved if it lacks any of the

above items. Each additional septic plan review is $75.00.

_______________________________ __________________ _________________

Septic Contractor Signature Date Phone Number






www.boonehealth.org

4”dia

6” rock below pipe

12”

rock

total

36”

Max

Depth

(Includes

fill)

Top of Foundation elevation (BM)

Foundation outlet elev

SYSTEM PROFILE (CROSS SECTION) New Construction must show all

Repairs must show: Tank outlet elev / existing grade (EG) / depth of existing line (if poss.) & proposed line

tank

______

System is: Level / Serial Dist. / Combination

Pipe elevations are: Invert / top of pipe

Filter is: in tank after tank

Filter specs:

Min 6” to Max 24”

fill dirt

EG = Existing Grade Elevations (Level fields only may show 1st & last lines)

Trench bottom (Tb) elev. _____ ______ ______ _____ ______ _____ _____ _____ _____ _____ _____ _____

Circle One:

Tb DEPTHS

EG (b)

_______gals atu

lift

_______gals

_______gals

EG (a)

Inverts

in

out

in

in

out out

Native soil

EG

____gals/ft of ht

Dose volume

_____ gals

Alarm on

Dose on

Dose off

Storage

volume

Must be ½ day

storage above

alarm set

_____ gals

Lift tank (specs.)

#1 #2 #5 #4 #3 #6

EG (a) EG (a) EG (a) EG (a) EG (a)

_____ ______ ______ _____ ______ _____ _____ _____ _____ _____ _____ _____

EG (b) EG (b) EG (b) EG (b) EG (b)

(a) (b) (a) (a) (a) (a) (a)

(b) (b) (b) (b) (b)

Static ____ gals

Boone County Health Department

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