HomeMy WebLinkAbout2018-10-17 - 160 Chapel Road - B100a Application9C4
Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074 — Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074 —Office Address
'�Utir,R.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 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
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Owner Name Mailing Address Telephone
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Applicant Name (if different than owner) Mailing Address 50v-j-k 5n✓ Telephone
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Describe the proposed structure or activity with dimensions:
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Residential __ZNumber of existing bedrooms
Non-residential Please describe
Property served by on -site well? Y (I If No, List name of water company
Property served by septic system? % 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 I00a 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 13100a. application approval and affirm
such with my signature below.
Applicant Signature:
FOR OFFICE USE ONLY:
Date: d o / 0 llF-
Approved: Y N By: Date:
Comments/Conditions:
FEE PAID: CHECK # DATE PAID:
Rev. 7/16/18
FOR OFFICE USE ONLY
Application Complete:
Form:
Plot Plan:
Building Plan:
Info Needed:
Soil Data Available:
Test Pits:
Perc Test:
Need Soil Data Y N
Activity
Building Conversion:
Change in Use:
Addition w/ Increase:
Addition w/o Increase:
Addition w/o Increase
Accessory Structure
Lot size reduction
Lot line change
General info
Notes:
Notes:
Notes:
Code Complying Area found Y N
Will proposed change result in expanding system? Y N
Notes:
OR potential repair area found that meets the following:
1. Replacement area provides 50% of ELA Y
2. Replacement area provides 50% of MLSS Y
3. No exception(s) to well separation distance Y
4. Does not reduce the potential repair area Y
5. Does not increase design flow of building Y
Code complying area? Y
Potential repair area identified? Y
Code complying area? Y
Will this negatively impact existing SSDS?
Will this negatively impact existing well(s)?
Area separation distances approved:
N
N
N
N
N
N
N
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Y N
Y N
Y N