TOWN OF HYDE PARK
SEWAGE DISPOSAL CONSTRUCTION APPLICATION
Copies of the septic regulations are available from the Town Clerk’s Office
and the Zoning and Planning Office.

FORM A

Tax Map#:____________ Road Name:__________________ Application#_______

Landowner: Applicant:(if different from owner)

Name:____________________________ Name:________________________

Address:__________________________ Address:______________________

Town/State/Zip:____________________ Town/State/Zip:________________

Phone#:__________________________ Phone#_______________________

General Information to be completed by Health Officer or Applicant:

A. Are there State Subdivision or Act 250 Permits for this property? If so #_______ Yes___ No____
B Is this an existing building? Yes___ No____
C. Lot size: _____________
D. Type of building: Residential____ Commercial____ Industrial____ Other____
Residential: Number of Bedrooms____
Commercial/Industrial: Maximum employees:____ Maximum number of public____
E. Water System: Drilled Well____ Shallow well or spring____ Municipal____ Private System____
F. Is the water supply or leachfield in the road right of way? Yes____ No____
G. This sewage disposal system is a: new system____ replacement system____ repair____
H. Type of system: Conventional____ Mound____ Other:____________________________

Plot Plan Requirements: The Engineer or Site Technician B shall submit a design showing the property, giving dimensions, showing location of water supplies with shields, all buildings, abandoned systems, buried lines, design details of the system, showing primary disposal area and replacement area, a north arrow, a bar scale and any other pertinent information.

DESIGN

I,________________________, Licensed Professional Engineer or On Site Technician B of the State of Vermont, stamp number______________, do hereby state the attached plans for the septic design have been designed in conformance with all state and local statutes and/or regulations, and accepted engineering principals for construction of septic systems. I understand that the Town of Hyde Park shall use this statement of design as one of the primary factors in granting a sewage disposal construction permit. If there has been any deviation from state and local statutes and/or regulations in the design, I understand that there will be a hearing and written decision from 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.

Dated at ____________________, Vermont this _____ day of _______________, 20_____.

____________________________________________ _______________________
Signature of Licensed Professional Engineer or Site Date
Technician B
(OVER)
The Town of Hyde Park does not undertake any responsibility for the effectiveness of any design it may approve for the Applicant. All designs approved by the Town of Hyde Park and submitted to the Applicant are without warranties of any nature whatsoever, and no action shall lie against the Town of Hyde Park, whether arising out of theory of contrast or theory of tort.

Signature of Applicant:____________________________________ Date:____________

Date Application Received:______________________ Fee $______ Paid_____________

Date Work Must Be Completed By: _______________

Preliminary Approval: Yes____ No____

Authorized Town Official:__________________________________ Date_____________

Final Approval: Yes____ No____

Authorized Town Official:__________________________________ Date_____________