HomeMy WebLinkAboutMisc Correspondence 24 Deerfield Lane South Windsor Health Department
B 100a application
(for building conversion, change of use, building addition, accessory structure and lot line change)
Address of proposed acZt1I_ZL1-
erpa"v,s , a �t z_16 3�
Owner Name Address telephone
Applicant name &address if different from above telephone
Describe the proposed structure or activity with dimensions (e.g. _ "addition with bedrooms, bathroom, family
in ound/below ground pool, deck, winte ing porch)
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Residential Number of existing bedrooms
Non-residential Please describe
Property served by on-site well? Y N Property served by public Ovate Y
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 B100a 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.
App4cant Signature Date
OFFICAIL USE ONLY
M INSPECTION REPORT
Page 5
Was a more in-depth investigation of leaching system conducted? no Y/N
What were the results?
Is there an expansion/repair area available? x Likely Not Likely Unknown
Were there any conditions observed which might limit a repair?(wetlands, ledge outcrops, streams, etc.)
No.
DIAGRAM OF TANK AND LEACHING SYSTEM LOCATION (ties from permanent structures):
1 3,0'6"
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1
David Hoover
Inspector's Name(printed or typed) Preparer's Signature
Profession: Installer LIC. No. 5435
This form is a result of a Connecticut Environmental Health Association Committee consisting of members of the State
Dept. of Public Health, Local Sanitarians, Licensed Installers, CT Sewage Disposal Association, CT Association of
Realtors and the Home Inspection Industry