HomeMy WebLinkAboutMisc Correspondence 167 Ayers Road South Windsor Health Department
B 100a application
(for building conversion, change of use, building addition, accessory structure and lot line change)
Address of proposed activity street number
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Owner Name Address telephone
Applicant name &address if dillerent from above telephone
Describe the proposed structure or activity with dimensions (e.g. _"addition with bedrooms, bathroom, family,
in ground/below ground pool, deck,winterizing porch)
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Residential ZNumber of existing m bedroos 3
Non-residential Please describe
Property served by on-site well? Y Property served by public water? Y N
Plot plan-attach a scaled drawing showing property lines and dimensions, location and size of
existing and proposed structures, and site features such as driveways, wells and septic systems,
drains and water courses.
Building plan-attach a sketch/floor plan of the proposed structure, addition or renovation showing
-existing and proposed rooms with door and window locations.
Soil test data(deep test pits and percolation test) are required for the review of this application.
If the data is not available, you will need to schedule an appointment with the health department.
As property owner or duly authorized representative of the property owner of the above referenced
property, I agree to permit the health department staff to enter the above referenced property as part
of this B 100a application review process. I further agree that this authorization to enter the subject.
property may extend through a period of time ending with the final B 100a application approval and
affirm such with my signature below.
Applicant Signature Date 1 U
OFFICAIL USE ONLY
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