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Permit No.______________________

APPLICATION AND PERMIT for DUST ABATEMENT OF COUNTY ROADS

(WORK IN THE PUBLIC RIGHT-OF-WAY)

TETON COUNTY ROAD AND BRIDGE DEPARTMENT

LOCATION/DESCRIPTION OF DUST ABATEMENT:

County Road Name: ______________________

Map Included: YES

Starting Location:________________________

Ending Location:_________________________ Total Feet:___________

Start Date ______________________________

Estimated Completion Date _______________________________

Applicant

Name: _____________________________________________________________________________________

Address (

) ____________________________________________________________________

include City / State / Zip

Phone: _________________________________ Cell Phone: ________________________________________

Product:

◊ Magnesium Chloride

◊ Other ____________________________________(MSDS Required)

Contractor

Business Name: ___________________________ Contact Name: ______________________________________

Address (

) ____________________________________________________________________

include City / State / Zip

Office Phone: _____________________ Cell Phone: _______________________ Fax: _____________________

______________________________

Applicant understands that the life of a dust control treatment to a gravel road is normally only through the dry season in which it is applied

and may be shorter depending on the traffic volumes and weather conditions. Applicant further understands that Teton County WILL NOT

maintain the road as a hard surface road and at the end of the dry season (Oct 1) will resume grading and rocking the road as needed in

accordance with adopted maintenance practices.

Applicant agrees that any and all corrective action that may become necessary because of failure to comply with the procedures and

conditions of this permit will be completely at the Applicant’s expense. Applicant further agrees that Teton County may cause corrective

action to be taken at Applicant’s expense should Applicant fail to take corrective action within the time specified by the County, or if Applicant

could not be notified within a reasonable amount of time of the need of corrective action.

The undersigned Applicant agrees:

INDEMNIFICATION: To the fullest extent permitted by law, Applicant agrees to defend, hold harmless, and unconditionally indemnify TETON

COUNTY, and all of their respective officers, directors and employees, against and for all liabilities, costs and expenses including attorney’s

fees and expenses of investigation, claims and damages which TETON COUNTY may at any time suffer or sustain or become liable for by

reason of any accidents, damages or injuries (including injuries resulting in death) either to the persons or property, or to any other parties,

in any manner caused by or resulting from Applicant’s breach of this Permit or acts or failures to act by Applicant or its employees or agents

in the performance of the Permit; provided, however, that such indemnification and hold harmless shall not apply to claims for loss, damage,

injury, or death to the extent caused by the negligence of TETON COUNTY.

That the Applicant has read and understands all of the foregoing requirements, restrictions and conditions; That, for valuable and sufficient

consideration, the Applicant is contractually obligated to TETON COUNTY to fully and faithfully abide by and perform all of the foregoing

requirements, restrictions and conditions; and in its sole discretion TETON COUNTY reserves the right to terminate this permit at anytime

upon written notice to Applicant mailed regular mail, postage prepaid to Applicant at the address shown here in. Said notice shall be effective

upon mailing. TETON COUNTY may also serve said notice on Applicant personally or by leaving a copy of said notice at Applicant’s place of

business or home.

(Initial)________

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Application And Permit For Dust Abatement Of County Roads Form - Teton County Road And Bridge Department

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