HomeMy WebLinkAboutSeptic Correspondence 920 Main Street South Windsor Health Department
B 100a application
(for building conversion, change of use, building addition, accessory structure and lot line change)
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Address of proposed activity street number n,
P[�y 7
Owner Name Address telephone
Applicant name &address if different from above telephone
6 X v" wi Gtee
Describe the proposed structure or activity with dimensions (e.g. _"addition with bedrooms,Mathroom, family
in ground/below ground pool, deck, winterizing porch)
Residential Number of existing bedrooms
Non-residential Please describe
Property served b on-site well? Y Property served by public water? 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, ou 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 applicatiorrapproval-and,
afI`um such with my signature below.
Applicant Signature Date g�-&-047
01
OFFICAIL USE ONLY
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<�•�.�� MAP TITLE Data provided by SBC under contract and is based on an
$ LEGEND aerial flight performed in spring of2005. This map is a bouhWindsor
c r MAP S V B—TITLE graphical representation of property information and is T
y' = 1
TOWN LINE f PARCELS subject to change. The Town of South Windsor and SBC a
assume no legal responsibility for information depicted on
1 inch = 40 feet this map and is to be used for planning purposes only.
Post-it®Fax Note 7671 Date
To From
Co./Dept. N Co.
Phone# Phone#
Fax# Fax#
N
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NOTES : Septic layout not to scale. SOUTH WINDSOR POLLUTION CONTROL
LOCATION 920 Main Street
OWNER Vernon 0. Petersen
TYPE OF WORK Septic Repair
DATE10 08 71 PERMIT 1-62 PIPE4t't O.B.
INSTALLER Silvester W9-355 3O
INSPECTOR ME DRAWN BY ME