B100a / Change in Use Application
INSTRUCTIONS

This form is used to conform to the State of Connecticut Public Health Code, Section 19-13-B100a, which governs building conversions and/or changes in use to existing structures, building additions, garages/accessory structures, swimming pools and sewage disposal area preservation.

You are filling out this form to provide the local health department with important information to assure that you:

•	Do not build any structures on top of an existing septic system
•	Conform to the required separating distances and maintain your property according to the Connecticut Public Health Code

In addition to filling out this form, you will also have to submit the following with your application:

□	If your home was built prior to 1985, please have your deed or the previous owners name available. This information can be obtained from your Town Clerk.

□	A plot plan drawn to scale (Example: 1inch = 20 feet) which shows the location of the house, well, sewer line, and closest property lines. Be sure to indicate distances between each item.

□	A written description of the proposed addition, accessory structure or pool.

□	If proposing an addition to an existing structure, please provide a sketch of the existing floor plan and a sketch of the proposed floor plan change.

Exemptions
You are not required to file a B100a Application for the following:
•	Accessory buildings or sheds less than 200 square feet which will sit directly on pressure treated plywood or concrete blocks and do not require the pouring of a concrete slab, frost protected footings, sonar tubes or any other foundation that would disturb the soil.
•	Anchoring kits that prevent uplift due to winds which are used for temporary structures like removable carports. Anchors should not penetrate the septic system. (Please note, anchoring kits that require the pouring of a concrete slab or permanent footings do require a B100a application.)
      In the event of application withdrawal by the applicant, NDDH reserves the right to retain a non-refundable processing fee.

In order to avoid unnecessary delays, please be sure to complete the form in its entirety and submit all required information and fees. Do not fax, return by mail.
For additional assistance, please contact us: email@nddh.org 

Northeast District Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234
Phone – (860) 774-7350 / Fax – (860) 774-1308
     www.nddh.org		email@nddh.org

Sanitarian Approved Initial:	 Date:  	

Emailed: 	

Northeast District Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234
Phone – (860) 774-7350 / Fax – (860) 774-1308
     www.nddh.org		email@nddh.org 

B100a /Change in Use Application
To conform to PHC 19-13-B100a – Building Conversions/Changes in Use, Building Additions, Garages/Accessory Structures, Swimming Pools, Sewage Disposal Area Preservation

Street #: 		 Street: 					 Town: 			
Assessor’s Map: 		 Block: 	 Lot: 		Dev. Lot: 		 Lot Size: 	

Legal Owner: 												
Mailing Address: 											
Town: 						 State: 			 Zip: 				
Contact Phone:				 Email Address: 						
Year Built: 						No. of Bedrooms: 				
Description of proposed change/addition:								

Agent for Owner: 											
Agent’s Mailing Address: 										
Town: 						 State: 			Zip: 				
Agent’s Phone Number: 				Email Address:					
		
*************************************************************************************

PROPERTY OWNER: By signing above, you certify that the information provided is a true and accurate description of the addition, accessory structure, or pool. No services will be rendered until payment is received. This form may be submitted by email, mail, or fax.  In the event of application withdrawal by the applicant, NDDH reserves the right to retain a non-refundable processing fee.
(If working on behalf of owner, please attach signed Letter of Consent)

	Signature of Legal Property Owner					Date

*************************************************************************************

NDDH Use Only		
Date: ___________ Fee: _______ Check # _________     CC    E-Check     Cash     Receipt #_________________   

Sanitarian Approved Initial:	 Date:  	

Emailed: 	

Northeast District Department of Health 
69 South Main Street, Unit 4
Brooklyn, CT 06234
Phone - (860) 774-7350 / Fax - (860) 774-1308
www.nddh.org                email@nddh.org 

LETTER OF CONSENT

______________________________ (DATE)

To Whom It May Concern:

I, ________________________________________, legal property owner of:

Street: _________________________________, Town: ________________________

Map #: __________, Block #: __________, Lot #: _______, Dev Lot N#: ________,

As recorded in the Town Assessor’s Office, do hereby authorize:

to act as my agent and grant permission to apply for:

1.	______________ 	Soil Testing

2.	______________ 	Permit to Construct or Repair a Septic System 
	
3.	______________ 	Other: ___________________________________________

In evaluating this application, I realize that the Northeast District Department of Health has relied on information provided by the applicant or agent.  If such information subsequently proves to be false, deceptive, incomplete and/or inaccurate, service will be suspended, and any permits issued will be revoked.  I understand that a permit to construct is issued to a specific CT Licensed Installer, is the property of the installer, and is not transferable.

The undersigned swears that the information supplied in the completed application is accurate to the best of his/her knowledge and belief.

________________________________	________________	_________________
Signature of Legal Property Owner		Date 			Telephone #

________________________________	________________	_________________
Signature of Appointed Agent			Date			Telephone #