SOUTH DAKOTA DEPARTMENT OF TRANSPORTATION APPLICATION FOR PERMIT TO OCCUPY RIGHT OF WAY 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 (City or well defined point) Section Township Range Description of occupancy: Purpose of occupancy: Duration of occupancy: PERMANENT TEMPORARY If temporary, give the estimated date of removal or completion: 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. To furnish all materials, labor, incidentals and pay all costs involved with this occupancy including restoration of any damage to the roadway and right-of-way to equal or better conditions than existed prior to the occupancy covered by this permit. To provide protection to highway traffic during occupancy by the use of proper signs, barricades, flagpersons and lights as prescribed in the "Manual of Uniform Traffic Control Devices." 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. APPLICANT NAME (please print)____________________________________________________________________ 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 TELEPHONE REPRESENTING (Name of Individual, Company, Organization, etc.) ------------------------------------------------------------------------------------------------------------------------------------------------------ ***To be completed by Department of Transportation*** Project (Const.) ________________________ Station ____________________ Milepost ____________________ Project (Maint.) _______________________________ Maintenance Unit ___________________________________ Prior to commencing occupancy and at completion of occupancy the applicant shall notify ______________________ at _____________________________________________ Telephone ___________________________________ Special Conditions __________________________________________________________________________ ____________________________________________________________________________________________ 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 the right-of-way is granted to all conditions as herein stated on this ____ day of ____________, 20____ . ________________________________ ____________________________________________________ Region Engineer Chief Bridge Engineer (Bridge Installations only) INSTRUCTIONS FOR DOT-295 APPLICANT: Complete all items at the top of the form. If the occupancy involves work within the right-of-way, prepare a separate sheet showing the work to be accomplished. The drawing should include: Width of the highway from shoulder to shoulder Width of the right-of-way Details of the work to be performed by the occupancy A North arrow Installations on bridges must include details of the method(s) of attachment. Any other pertinent information Sign the form and submit it and any attachments to the Region Office for processing. DEPARTMENT OF TRANSPORTATION REGION OFFICE: Complete the bottom portion of the form. Installations involving bridges require review/approval of the Chief Bridge Engineer. If review by the Office of Bridge Design is necessary, allow two weeks for review. If the request is denied, return the request to the applicant and state the reason for denial. If the request is granted, make and send copies of the permit and attachments to: Applicant Area Engineer Maintenance Supervisor Chief Bridge Engineer (if applicable) File the original copy in the Region Office. NOTE: After Region Engineer (and Chief Bridge Engineer if necessary) approval, requests on Interstate Highways are to be forwarded to the Office of Right-of-Way to obtain the concurrence of the FHWA. Data will be returned to the Region Office for distribution.