(Pursuant to
Town of Angelica Ordinance 7-11-05)
Name of Applicant:_____________________________________________________________________
Address:______________________________________________________________________________
Phone Number:__(_______)________________________
Upon an on-site inspection on _______________________________________, the above-named
(Date)
applicant is given permission to install a ____________________________________________culvert to
(Dimensions)
be __________________________________________________________________________________
(Location Requirements)
and__________________________________________________________________________________
(Special Conditions)
on/at_________________________________________________________________________________
(Address)
The applicant agrees to the requirements and specifications, a summary of which are listed on the reverse side of this permit, of the Town of Angelica Driveway/Culvert Ordinance.
_______________________________
Applicant’s Signature
________________________________
Date
________________________________
Town of Angelica Issuer
_________________________________
Date
FEE: ____ $30.00 for a building
____ $15.00 for a field entrance
____ $50.00 commercial entrance
8-13-07