2. Owner*
3. Phone Number*
5. Address*
7. City
8. State
9. Zip Code
13. LOCATION
15. Length of Road*
    Indicate the length of road to be treated in feet.
16. Material To Be Used*
18. Township Name*
    -- Select One --AldenHardinEtnaBuckeyeEllisJacksonClayShermanTiptonPleasantEldoraConcordGrantProvidenceUnion
19. Township*
    -- Select One --T89NT88NT87NT86N
20. Range*
    -- Select One --R22WR21WR20WR19W
21. Section*
    -- Select One --123456789101112131415161718192021222324252627282930313233343536
23. Contractor Name*
27. Notice
    THE SIGNUP DEADLINE FOR OBTAINING A DUST CONTROL PERMIT IS APRIL 28TH. AFTER THAT DATE, A $25 LATE FEE WILL BE ASSESSED.
29. Conditions of Permit
    The application and maintenance of chemicals to control dust on crushed rock surfaced roads shall be by permit only and in accordance with the following conditions:
    
    1. Road chemicals may be applied by the owner or an approved contractor for owner.
    
    2. The only materials approved for use on the roads are calcium chloride, magnesium chloride, and lignin sulfonate. Used motor oil is not allowed per the Environmental Protection Agency.
    
    3. The owner shall maintain the treated area and repair any roughness that may develop.
    
    4. The County reserves the right to rework the treated areas and maintain them as loose granular surfaces, without notice to the owner, if the owner fails to maintain the area in a condition acceptable to the County, and at no cost to the County.
    
    5. On or about mid-October dust control locations will be bladed through in preparation for winter weather.
31. Electronic Signature of the Owner or Agent*

    1. Selecting this option indicates agreement with and understanding of the Conditions of Permit.
35. Permit Approval
    Complete to indicate approval of Dust Control Permit.
36. Date
    Date
38. Motor-grader Operator Name
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field