HomeMy WebLinkAboutSeptic Correspondence 179 Palmer Drive 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
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 ground/below ground pool, deck, winterizing porch) j
Residential V Number of existing bedrooms
Non-residential Please describe
Property served by on-site well? Y N 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, vou will need to schedule an appointment with the health de artment.
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 applicatioirapprovalJand-
affirm such with my signature below.
Applicant Signature Date /
OFF CAIL USE ONLY
Electric # APPLICATION FOR BUIL INQ PERMI'
Plumbing#
HVAC# Date:
Sprinkler#
FINAL APPROVALS Estimated Cost $ (Jd0
Building COMPLETE RED BOXED AREAS Permit Fee $
Engineering TYPE OR PRINT ONLY Occupancy Fee $
Affidavit Eng. Insp. Fee $
Appr.for CO. SIGN ON REVERSE SIDE t
Total Fee $
TO THE BUILDING DEPARTMENT, TOWN OF SOUTH WINDSOR, CT (Additional Cost) $
The undersigned hereby applies to do work according to the following:
Applicant Location of Work Lot No.
Applicant's Address !/ -) V Tel # �4-� !�W�a- �
Town
.1d1 Zip Lic.#
Owner Ir 67, �_ Architect
Owner's Address 17/ PWM69— Ae. Architect's Address
l� Zip Zip
Sq. Ft. New Area: 1 st FI. ��y 2nd FI. 3rd FI. Total New Area /G
Purpose of this permit BV/LA)/`yG p�
City Waterlo Well ❑ Septic System Sewer U
Ins: HO SP Cert. Area Basement Garage
Approved by Date Use Group Construction Type
Revised 1101