TOWN OF HYDE PARK
SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT

FORM B

Name of Applicant:______________________ Application#_____ Tax Map#_________

CONTRACTOR

I,________________________, of________________________(Company), a contractor in the State of Vermont, do hereby certify that the septic system designed by __________
___________________, a Licensed Professional Engineer or a Site Technician B for _____________________________(applicant), has been installed by ________________
________________(Company), in accordance with the design plans dated ___________,
19___, and the installation was done in a good workmanship manner. It is understood that the Town of Hyde Park shall use this statement as one of the primary factors in granting approval. It is also understood that the contractor is not a Licensed Professional Engineer or a Site Technician B.

Was the sewage disposal system installed as designed? Yes____ No_____
if No, explain the deviation and reason for deviation:___________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.

Signature of Contractor:__________________________________ Date ___________