HomeMy WebLinkAboutSeptic Repair 23 Gordon Drive Town of South Windsor — Health Department
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1540 Sullivan Avenue, South Windsor, CT 06074
s Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
R-co 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.
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Street Address of Proposed Activity/Structure
Owner Mime Mailing Address Telephone
Applicant Name(if different than owner) Mailing Address Telephone
Describe the proposed structure or activity with dimensions:
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Residential Number of existing bedrooms_
Non-residential Please describe
Property served by on-site well? Y dV If No,List name of water company
Property served by septic system?' N Age of system 9 - Date last pumped 'lUoy,
Plot plan—attach a sc ed 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 a ointment 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: Date: & 1
FOR OFFICE USE ONLY: r
Approve N By: Date: I (�
Comments/Conditions:T6 SCA l ln- O(A i�?Cu!�_ JZ ,���/ FD
SOUTH WINDS051y 2011
HEALTH DEPT
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