TOWN OF HYDE PARK
SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT

FORM C

Name of Applicant:_______________________ Application #____ Tax Map#________

INSPECTION

I, ___________________________ a Licensed Professional Engineer or Site Technician B, of _________________________(Company), stamp number _______, certify that I have inspected the sewage disposal system designed by __________________________, on plans dated _____________, 19__, and installed as designed by _________________
________________. It is understood that the Town of Hyde Park shall use this statement as one of the primary factors in granting approval.

Was the sewage disposal system installed as designed? Yes____ No____
if No, explain the deviation and reason for deviation:__________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

If deviations were made, I shall attach a written narrative and as built plans are to be attached to this form. If there has been any deviation from state and local statutes and/or regulations in the design, I understand there will be a hearing and written decision by the Hyde Park Board of Health, authorizing the deviation, which cites their authority to make such a deviation, and it will be attached to the design plans.

It is understood that the Town of Hyde Park shall use this statement as one of the primary factors in granting approval.

Dated at _________________, Vermont this ____ day of ____________ 20__.

________________________________________ _________________
Signature of Licensed Professional Engineer or Date
Site Technician B