HomeMy WebLinkAboutMisc Correspondence 26 Woodland Drive 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
/ RUO-Uy1f-GSL09
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, bath7famnily in ground/below ground pool, deck, winterizing porch)
Inn 12
Residential 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, you will need to schedule an aDDOintment 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 m si nature belo V.
Applicant Signature Date ( ��
FFICAIL USE ONLY