NHDOT's Excavation Permit

Maintenance District Six- Excavation Permit

TO:  Michael J. Burlage, PE, District Engineer                                     ________________________ 20____

        Pursuant to RSA 231:184, 185, 186 and RSA: 9, 10, 11, permission is requested to disturb the surface, shoulders, ditches, or slopes of the ___________________________ road/highway in the City/Town of _______________________ for the purpose of __________________________________________________________________________________________________________________________________________________________________________________________________________________________

               I/We herby agree to conform to the following instructions and regulations in regards to the performance of the work proposed under this request.   I/We also agree to any additional instructions issued by the District Engineer, or his authorized representatives, during the process of the work.

               If possible, the pipe must be jacked.  Small pipes are to be laid in a sleeve.  If the pavement has to be disturbed, it must be cut prior to excavating.  (Except emergencies)  The pavement and base course material are to be discarded.  Excavation below sub-grade is to saved and used for backfill.  This is to prevent differential frost heaving.  After the _________________________________________________ the disturbed area must be backfilled, using excavation, in layers not exceeding 12 inches, up to sub-grade.  Each layer is to be thoroughly compacted.  The base course shall be replaced as it was constructed.  Do not exceed the depth of the existing base course.  Crushed gravel is to be used if only one type of base course material is encountered.  Each layer is to be thoroughly compacted to not less than 95% of AASHTO, Test T99 (Standard Proctor).

               The pavement must be replaced under the direction of the Patrol Foreman listed below.  Please notify him/her at least 24 hours before doing any patch work.  The patch depth shall equal the depth of the existing pavement.  The edges of the pavement shall be trimmed as needed.  Hot bituminous concrete (Hot Top) shall be used for all patching material unless otherwise stated.

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Earth areas disturbed will be replaced in kind, loamed, fertilized, seeded and mulched.  During the performance of this work, interruption of traffic must be kept to a minimum.  Signs and flag persons shall be used as needed to control traffic.  The area will be protected at night with barricaded, signs, lights, etc.

               I/We, the owners, agree to save harmless the State of New Hampshire from any and all claims arising from the construction, maintenance and operation of the said item(s) described in this permit and it appurtenances and agree to obtain permits from the District Engineer before performing any future excavation for maintenance or renewal of the said item(s) described in this permit or other appurtenances thereto within the highway limits.  I/We, the owners, agree to assume such additional cost as the State may incur due to the maintenance, operation, renewal or extension of said item(s) described in this permit or other appurtenances thereto within the highway limits.  It is understood and agreed that this permit is for the right of construction, occupancy, operation and future maintenance of the said item(s) described in the permit and is by sufferance only, with the State reserving the right to require, in event of future alterations of the highway, or highway right of way, certain alterations, relocations, or complete removal of said item(s) described in this permit and we, the owners agree to perform such work promptly and at our own expense..  Also I/We herby agree to assume such additional costs as the State may incur, by reason of my/our failure to perform this work in the manner prescribed above, and am familiar with the penalty imposed by RSA 236:14.

Area Patrol Foreman _______________________________________________  Tel. Work ____________

Leon S. Kenison, Commissioner, N.H. Department of Transportation

Permit No. _________________________ Date ___________________________________

Approved by: _______________________________________ District Engineer