SOUTH DAKOTA DEPARTMENT OF TRANSPORTATION
APPLICATION FOR ADOPT-A-HIGHWAY

Highway No. County AURORA BEADLE BENNETT BON HOMME BROOKINGS BROWN BRULE BUFFALO BUTTE CAMPBELL CHARLES MIX CLARK CLAY CODINGTON CORSON CUSTER DAVISON DAY DEUEL DEWEY DOUGLAS EDMUNDS FALL RIVER FAULK GRANT GREGORY HAAKON HAMLIN HAND HANSON HARDING HUGHES HUTCHINSON HYDE JACKSON JERAULD JONES KINGSBURY LAKE LAWRENCE LINCOLN LYMAN MARSHALL MCCOOK MCPHERSON MEADE MELLETTE MINER MINNEHAHA MOODY OGLALA LAKOTA PENNINGTON PERKINS POTTER ROBERTS SANBORN SPINK STANLEY SULLY TODD TRIPP TURNER UNION WALWORTH YANKTON ZIEBACH
From: (Street) (MRM) To: (Street) (MRM)

I, the undersigned, request permission to occupy public right-of-way at the above location and as shown on the attached layout sheet. In consideration for this permission, I agree to abide by all conditions as herein stated.

1. To indemnify and hold the State of South Dakota, its Department of Transportation, its officers, agents and employees, harmless from and against any and all actions, suits, damages, liability or other proceedings of any kind or nature brought because of any injuries or damage received or sustained by any person or property on account of the use or occupancy of right-of-way designated in this application.
   
   
2. To require all adult participants to complete and sign the release and waiver of liability, assumption of the risk and indemnity agreement and consent to medical treatment form prior to occupancy of right-of-way designated in this application.
   
   
3. To require all parents and guardians of minors to complete and sign the parents or guardians release and waiver of liability, assumption of risk and indemnity agreement and consent to medical treatment form prior to occupancy of right-of-way designated in this application.
   
   
4. To maintain an original signed copy of the forms identified in items 2 and 3 above for a period of three (3) years. Copies of these waivers shall be made available upon request of the Department of Transportation.
   
   
5. To comply with all other requirements contained in the latest version of the DOT Adopt a Highway Policy.
   
   

PRINT NAME:_____________________________________________ TELEPHONE:

SIGNATURE: _____________________________________________ DATE: _______________________

ADDRESS: AK AL AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
REPRESENTING:
(Name of Individual, Company, Organization, etc.)

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***To be completed by Department of Transportation***

Milepost ____________________ To Milepost ____________________ Maintenance Unit _______________________

1. Prior to commencing occupancy and at completion of occupancy the applicant shall notify ____________________
   
   ________________________________________________________________________________
   
   
2. Special Conditions _________________________________________________________________________
   
   ____________________________________________________________________________________________
   
   
3. Failure to accomplish the occupancy in accordance with the provisions of this permit will automatically render this permit null and void and where applicable, constitute grounds for its removal and/or full restoration of the occupancy site, all at the applicant’s expense.
   

This permit to occupy right-of-way is granted to all conditions as herein stated on this ____ day of ____________, 20____ .

________________________________
Area or Region Engineer

INSTRUCTIONS FOR DOT-295A
APPLICANT:

1. Complete all items at the top of the form.
   
2. Sign form and submit it and any attachments to the Region or Area Office for processing.
   

DEPARTMENT OF TRANSPORTATION REGION or AREA OFFICE:

1. Complete bottom portion of form.
   
2. If request is denied, return request to the applicant and state the reason for denial.
   
3. If request is granted, make and send copies of permit and attachments to:
   • Applicant
   • Maintenance Supervisor
   • Area Office, if Region Office is the originating office.
     
4. File original copy in originating Office.