DOT 200: Application for Utility Permit (9/15) South Dakota Department of Transportation, Office of Operations Support 700 E. Broadway Ave., Pierre, SD 57501-2586 Questions? See bottom of form for Area Engineer phone numbers. 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 Approximately miles N S E W from for construction of (city or well-defined point) (type of utility facility) Begin legal description End legal description Intended usage or rating Cable size/type Casing size/type Outsize pipe diameter Maximum pipeline operation pressure Minimum depth, cable or pipeline (under rural highway 48”) (under curb/gutter 24”) (all other areas 36”) (overhead) Method of installation Approximate construction dates: Start Finish Special conditions I, the undersigned, request permission to construct and maintain a utility facility on public right of way at the above location and as shown on the attached layout sheet and in accordance with provisions of Administrative Rules of South Dakota (ARSD) 70:04:05. In consideration for this permission, I agree to abide by all conditions of said rules, and in addition, the following: This Utility Permit does not replace any other permit, license or other approval that may be required by any other entity holding a property interest in the right of way, including but not limited to any tribal government, the Office of School and Public Lands, the U.S. Forest Service and the Bureau of Indian Affairs. The issuance of this Utility Permit does not relieve the applicant of the obligation to obtain any other approvals that might be required for use of the highway right of way for utility purposes. The applicant is solely responsible for investigating whether additional approval is required and complying with any other applicable requirements. If the applicant fails to secure all necessary approvals or comply with all applicable requirements, this permit is of no effect whatsoever, and the South Dakota Department of Transportation (SDDOT) may, at the applicant’s sole expense, cause the immediate removal of the utility facilities. To furnish all materials, labor, incidentals and pay all costs involved with the construction and maintenance of the utility facility. To perform approved open-cut trench operations in accordance with current SDDOT Open Cut Method of Utility Installation or Repair, ARSD 70:04:05, Appendix A. To restore any damaged portions of the roadway and right of way to equal or better conditions than existed prior to beginning work covered by the permit. To not install a utility over the top of any highway drainage structure. To permanently mark above-ground pedestals/facilities with metal flags or markers located at least 48” above ground. If deemed necessary by the SDDOT, to move or alter the utility installation in any way due to maintenance or highway construction within its present right-of-way width, the alteration will be accomplished by the owner without cost to the State. To provide protection to highway traffic during construction and maintenance by use of proper signs, barricades, flag persons and lights as prescribed in the current edition of the Manual on Uniform Traffic Control Devices. Workers are required to wear high-visibility safety apparel intended to provide conspicuity during both daytime and nighttime usage, and meeting the Performance Class 2 or 3 requirements of the ANSI/SEA 107-2004 publication “American National Standard for High-Visibility Safety Apparel and Headwear.” To indemnify and hold the State of South Dakota, the SDDOT, 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 highway right of way designated in this application. Company Date Email address Address City State 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 Zip Phone By ____________________________________ Print or type Title Signature TO BE COMPLETED BY THE SOUTH DAKOTA DEPARTMENT OF TRANSPORTATION Project ______________________________________ Milepost _______________________________ Maintenance Unit __________ 1. Prior to commencing construction and upon completion of work the applicant shall notify _____________________________ __________________________________ at ___________________________________. Phone ________________________ 2. Special conditions _____________________________________________________________________________________________________ 3. Failure to construct and maintain the utility facility in accordance with the provisions of this permit will automatically render this permit null and void, and constitute grounds for its removal and/or full restoration of the site at the applicant’s expense. Recommended ___________________________________ Date ____________ ___________________________________ Date ____________ City Representative Bridge/Road Design Approved _______________________________________ Date ____________ Area Engineer Approved _______________________________________ Date ____________ Region Engineer This permit to construct and maintain a utility facility is granted subject to all conditions as herein stated.