HomeMy WebLinkAboutSeptic 48 Beelzebub n 0 -Te
e4 Town of South Windsor — Health Department
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�p o 1540 Sullivan Avenue, South Windsor, CT 06074
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Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
dS°A"`°N 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.
Street Address of Proposed Activity/Structure
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Owner Name Mailing Address Telephone
b� C"�N-
Applicant Name(if different than owner) Mailing Address Telephone
Describe the proposed structure or activity with dimensions:
Residential Number of exsting bedrooms Ja
Non-residential Please describe
Property served by on-site well? (Y�' N If No,List name of water company
Property served by septic system? Y ' J 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.
filuApplicant Signature:1 /�i?ro AL 2G6Ze Date:
FOR OFFICE USE ONLY-
Approved: 6 N By: Date: ZU I tr _
Comments/Conditions: w `� c✓'rn�Y\ S 10 ' W"e
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May 2011
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THOMAS JM4ES CLOSE & ELIZABLTH B. CLOSE
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