HomeMy WebLinkAbout2012-10-12 - 16 Green Lane - B100a ApplicationTown of South Windsor — Health Department
1540 Sullivan Avenue, South Windsor, CT 06074
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
I31004 APPLICATION H 1'rk P
(for building conversion, change of use, building addition, accessory structure and lot line change) 4N
plication review time is 5-10 days, if soil testine is needed. additional time will be required to complete the review pro
Street Address of Proposed Activity/Structure
ivj Li w &, /6 c6p'r' ;u�;2161' 1967
Owner Name Mailing Address
Applicant Name (if different than owner) Mailing Address
Describe the proposed structure or activity with dimensions:
Residential ` Number of existing bedrooms 3
Non-residential Please describe
Property served by on -site well? Y N� If No, List name of water company
7'??011?
g6o- 4 zzv
Telephone
Telephone
Property served by septic system? l) N Age of system 7 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 B 100a application
approval and affirm such with My si ature below.
,J
Applicant Signature*-- Date: /O /U �- - -
FOR OFFICE USE ONLY:
11
Approved: Y) N 133•: Date: t b !d 12-
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Comments/Conditions: t'c.�♦: ,n r . N la2V-1 r�
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U May 2011