HomeMy WebLinkAbout20170724135622 e\ '6 •� -� Town of South Windsor — Health Department
1540 Sullivan Ave.,South Windsor,CT 06074-Mailing Address
1530 Sullivan Ave.,South Windsor,CT 06074-Office Address
Phone Number: (860)337-6173,Fax Number: (860)644-1930
B100a APPLICATION
(for building conversion,change of use,building addition,accessory structure and lot line change)
Standard application review time is 5-10 dai1s,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 'relep one
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pplicant ante(if different than owner) Mailing Address Telephone
Describe the proposed structure or activity with dimensions:
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Resides Nunlhcr of existing bedrooms
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Non-residential Please describe //
Property served by on-site well? Y if No,List name of water company
Property served by septic system' Age of system Date last pumped
Plot n—attach a scaled drawing sho 'ng property lines and dimensions,location and size of existing and proposed
. ructures,and site features such as driveways,wells and septic systems,drains and water courses.
B ilding plan—attach a sketch/floor plan of the proposed structure,addition or renovation showing existing and
proposed rooms with door and window locations.
it 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 9foperty may extend through a period of time ending with the final B 100a application
ap royal and affirm such with my si atur elow. /
Applicant Signatu
Date: r l
FOR OFFICE USE ONLY:
Approved N B�• ///s><i� �'—p � ' r`� Date: A,
Comments/Conditions:
May 2011