HomeMy WebLinkAboutSeptic Correspondence 333 Griffin Road Town of South Windsor — Health Department
1540 Sullivan Avenue, South Windsor, CT 06074-2786
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
B100a APPLICATION
(for building conversion,change of use,building addition,accessory structure and lot line change)
Standard application review time is 5-10 days,if soil testing is needed additional time will be required to complete the review process.
3 (�;r-`
Street Address o oposed ctivity, tructur
JC
Z.'�
sue. 3�3�'r
Owner fUme Mailing Address Telephone
`5 Q_
Applicant Name(if different than owner) Mailing Address Telephone
Describe the proposed structure or activity with dimensions:
Residential_,�Number of existing bedrooms
Non-residential Please describe
Property served by on-site well? 0 N If No,List name of water company
Property served by septic system?'D N Age of system Date last pumped
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 for soil testing.
As property owner or duly authorized representative of the property owner of the above referenced property,I agree to allow 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: o`er, Date: /
FOR OFFICE USE ONLY:
Approved: N By: Dater it
Comments/Conditions: J
May 2011
FOR OFFICE USE O N L Y
Application comt�IleCe:
Form: �/
Plot Plan:
Building Plan:
Information Needed Y Notified Applicant
Soil Data Available
Test Pits
Pen;Test
Need Soil Data Y N Notified Applicant Scheduled
Activity
Building Conversion Code complying area found Y N
Change in use Will proposed change result in expanding system? Y
Addition w/increase
of flow
Addition w/no increase
of flow
Addition w/no increase potential repair area found that meets the following conditions:
of flow 1. Replacement area provides 50%of effective leaching area Y N
2. Replacement area provides 50%of MLSS requirement Y N
3. No exception(s)to well separation distance is required Y N
4.The addition does not reduce the potential repair area Y N
5.The addition does not increase the design flow of the building Y N
Accessory structure Code complying area? Y N
Potential repair area identified? Y N
Lot size reduction 1 Code comp) ng area? Y N
Lot line change
Will this activity negatively impact existing sewage disposal system? Y
General Information Will this activity negatively impact existing well(s)and/or drains?
Are separating distances okay? Y N
Notes:
# PItIMUSNGINEERS � _�
IOS►O'f�titYi
t `w'-'+< s^rc1�+✓ -:r� a:,`Y,t'lY 3' �`t''"'£ a� t3
� f
ID
-
adai K' {
t i
7 30 i
f
36
kgcoi. i
FOUNDATION CHECKED -
DATE iI ^, AC AA,F
f CERTIFIED SUBSTANTIALLY CORRECT
`i
SIS11EDC. 2ATE L f_
%/ / J ? SIG14 E-D-'/._.__ - �'f 1 j C �C r. ..c._✓