Form M-21 Revised: September TRANSPORTATION COMMISSION OF WYOMING and its UTILITY SERVICE/REPAIR PERMIT 1. Parties. The parties to this License are, hereinafter referred to as Permittee, whose address is and the TRANSPORTATION COMMISSION OF WYOMING and its WYOMING DEPARTMENT OF TRANSPORTATION, hereinafter referred to as Agency, whose address is 50 Bishop Blvd, Cheyenne, WY 809-3340. 2. Purpose of Permit. The Agency hereby grants permission to the Permittee to (Description of work to be done) to/on their existing hereinafter referred to as Facility, located at: Street City/Town Section(s) Township Range County (ies) Route Milepost (RM) Company Tracking Number: GPS Coordinates: GPS Datum NAD/83 accuracy to ±' in decimal/degree format (e.g. Latitude 44.12345, Longitude -106.54321). For encroachments, attach Form M-54G Additional GPS Coordinates - included in the permit packet. Entering R/W: Latitude Longitude Exiting R/W: Latitude Longitude M-54 Folder Number ML: FOR DISTRICT USE ONLY M-54 Dist Ref Number: Maintenance Section: M-21 Dist. Ref. Number: 3. Plan/Staking Sheet. The Utility shall attach hereto a plan sheet and/or staking sheet showing facilities to be repaired, maintained or having new service connections as part of this Permit. This plan sheet, shall be designated Exhibit A and made a part of this Permit. The Exhibit A shall comply with the Wyoming Department of Transportation Utility Accommodation Regulation and shall include the following requirements. Existing roadway, right-of-way line, right-of-way fence, and cross fences if they are not on the right-of-way line. Existing approaches, intersecting roads or streets, drainage ditches, irrigation ditches, pipes, and culverts that have to be crossed. Proposed facility alignment with offset distances from either the roadway centerline or right-of-way line. Location of existing facilities on the highway right-of-way that are owned and operated by the Company. Proposed locations of all support appurtenances such as air relief valves, manholes, pedestals, junction boxes, line marker, vent pipes, guys and anchors, etc. Size and/or capacity of the proposed facility, that is, kv, number of cable pairs, pipe diameter, pipe type, wall thickness (for carrier and casing), product to be carried, max. operating psig, etc. Indicate with a highlighter, appropriate symbol, or verbiage (for example, As-Constructed ) the new facility so that it is easily recognizable for someone reading the drawing(s). Legal description: Section, Township, and Range with North Arrow. Reference new facility to the nearest milepost marker using a compass direction and footage. Example: 1231' east of milepost. All bridge attachments must be reviewed and approved by the WYDOT Bridge Program. Bridge attachments should indicate if the facility is to be placed in an existing conduit or a new conduit on the bridge. Bridge attachments are addressed in the WYDOT Utility Accommodation Regulation. The preferred and maximum sheet size shall be 11 x 17. Page 1 of 2 Pages
Conditions. This Permit is subject to the following conditions: a. This Permit is for the purpose of providing new service connections to, maintaining or repairing existing licensed facilities and does not permit new construction or extensive replacement of utility lines; such work requires a Utilities License, Form M-54. New service connections shall fall under the provisions of the existing Utility License. b. The work allowed under this permit shall commence only after the execution of this permit by both parties. If due to an emergency, work must begin before a permit can be processed, verbal approval must be obtained from the District Maintenance Engineer and a permit executed as soon as possible. c. The Permittee shall perform all necessary work in the maintenance or tapping of the utility and the cost of such work shall be borne solely by the Permittee. The work to be performed by the Permittee shall include the following as deemed applicable by the Department: i. Sub-excavation of all unstable material and compaction of all backfill or special backfill to a density equal to the surrounding material or as defined by the Department. Density tests will be provided by Permittee whenever it is deemed necessary. ii. iii. iv. All backfill shall be placed to the top of the sub-grade and the surface course or courses shall be replaced by like or better materials. (Asphalt pavement shall be replaced with asphalt pavement and concrete by concrete pavement). Furnish, provide, erect and maintain all necessary barricades, lights, reflectorized signs and take all necessary precautions for the protection of the work and safety of the traveling public at the work area in accordance with Manual on Uniform Traffic Control Devices (MUTCD) or WYDOT s Traffic Control for Roadway Work Operations Manual. Boring or jacking shall be performed with a minimum of surface opening. d. If ground settlement or paving failure occurs after Permittee has completed backfilling and resurfacing the utility cut, the Department will correct such settlement or failure; and all labor, material and equipment required to make such correction will be billed to the Permittee. 4. Signatures. In witness thereof, the parties to this Permit, either personally or through their duly authorized representatives, have executed this Permit on the days and dates set out below, and certify that they have read, understood, and agreed to the terms and conditions of this Permit. The effective date of this Permit is the date of the signature last affixed to this page. PERMITTEE Printed Name and Title Signature Date ( ) - Phone Number E-mail CURRENT POINT OF CONTACT FOR COMPANY (If different from Permittee above) Printed Name and Title ( ) - Phone Number E-mail AGENCY District Representative Printed Name and Title Signature Date Page 2 of 2 Pages
M-21 Permit General Instructions A. Originated by: B. Guidelines: C. Distribution: D. Form: This form is originated by the utility owner with an M-54 license for the existing facility. This form is used in lieu of the M-54 License Form for access to WYDOT s right-of-way for maintenance and repairs as well as service taps to existing licensed facilities, for example water, sewer, and gas taps to individual customers. In case of leaks or other emergencies, it is more critical that the work be performed to remedy any hazardous situation and avoid further damage to the surrounding area. Under these circumstances, it is acceptable to contact the District Maintenance Engineer for verbal approval and then to complete this permit after the work has already begun. Form M-21 shall be approved by the appropriate District Representative. The Exhibit A shall meet the minimum requirements set forth in the Utility Accommodation Regulations Chapter V, Section 8. Exhibits for Licenses. These requirements are included in the Permit under item 3. For each Permit, the District shall give one copy to the Permittee (on site utility company representative shall have this in hand at time of work), retain one copy for District files, and mail one copy to the Utility Section in Cheyenne. The Utility Section will use the M-21 information to update the existing M-54 license information, GPS coordinates, current POC information, etc. Form M-21 is available from the Utility Section in Cheyenne, from the District office, or online at: http://www.dot.state.wy.us/home/engineering_technical_programs/utilities_section.default.html G:\PROJECT_DEVELOPMENT\DEV-UTIL\SHARED\M-21 PERMIT\M-21 September \M-21 Instructions_-0910.docx
Border Jct. BLACK STATE OF WYOMING PREPARED BY THE CONTACT THE DISTRICT MAINTENANCE ENGINEER IN THE DISTRICT AREA WHERE THE WORK IS TAKING PLACE DISTRICT NUMBER PHYSICAL ADDRESS MAILING ADDRESS (IF DIFFERENT) TELEPHONE NUMBER 1 3411 SOUTH 3RD STREET, LARAMIE, WY 870 7 745-2117 2 900 BRYAN STOCK TRAIL, CASPER, WY 801 7 473-3222 3 ELK STREET, PO BOX 10, ROCK SPRINGS, WY 82902-10 7 352-33 4 10 EAST BRUNDAGE LANE, SHERIDAN, WY 801 7 674-23 5 218 WEST C, PO BOX 461, BASIN, WY 82410 7 568-3413 M O N T A N A I D A H O 22 390 239 TARGHEE NATL. 390 391 Y E L L O W S T O N E Jackson P A R K N A T I O N A L BRIDGER TETON Teton 354 352 SHOSHONE SHOSHONE 1 296 294 NATL. CODY 291 290 1 295 295 132 1 POWELL A 171 170 174 133 137 138 35 170 33 32 37 5 Hot Springs 134 36 WORLAND 431 RIVERTON 433 175 173 432 172 136 BIGHORN 31 345 9O 338 343 A BASIN 434 Big Horn 435 436 Washakie 3 331 335 193 344 87 BUFFALO 336 SHERIDAN 196 190 Johnson 341 Sheridan 4 9O 192 GILLETTE 50 387 Campbel 9 6 Converse 2 87 95 387 93 93 51 1 12 BLACK 24 SUNDANCE 1 10 HILLS 24 1 1 1 9O HILLS 1 13 1 5 451 1 Crook NEWCASTLE 450 Weston 18 272 271 270 S O U T H D A K O T A U T A H 238 7 CASPER 139 LANDER 237 353 3 131 1 236 135 2 7 241 487 351 350 Natrona 1 232 231 233 Lincoln 1 EVANSTON Sublete 235 240 372 ROCK SPRINGS 374 375 374 412 GREEN RIVER 41 1 413 ASHLEY 410 4 3 77 73 Fremont 487 7 3O 72 12 LARAMIE 21 1 2 1 210 222 2 4 70 1 1 2 150 WASATCH Uinta Sweetwater Carbon 1 76 377 RAWLINS 371 72 71 76 13 370 1 7 74 DOUGLAS 18 90 91 319 94 270 319 317 31 1 3 3 312 34 21 1 Platte 10 Albany 218 2 315 321 273 313 Goshen CHEYENNE 217 223 Niobrara 318 1 0 157 TORRINGTON 156 154 92 152 1 3 158 153 151 2 2 215 213 2 Laramie N E B R A S K A U T A H C O L O R A D O
Form M-54G Created: November 13 TRANSPORTATION COMMISSION OF WYOMING and its Additional GPS Coordinates GPS Datum NAD/83 accuracy to ±' in decimal/degree format (e.g. Latitude 44.12345, Longitude -106.54321). Supply GPS coordinates for each encroachment into/out of WYDOT s right-of-way or for each change in direction within the rightof-way. You may disregard this form if your license exhibit contains this information.. 1 4 5 2 3 Utility line WYDOT Right-of-way line Highway (pavement) 6 WYDOT Right-of-way line 1, 4, 5, 6 = enter/exit ROW 2 and 3 = change in direction within ROW Use the diagram below to label your GPS locations per the above example. 1 41.2943-105.560232 (Enter) 2 41.291574-105.560232 (Change) 3 41.291560-105.5108 (Change) 4 41.2935-105.5104 (Exit) 5 41.29-105.5500 (Enter) 6 41.290781-105.5588 (Exit) Location 1 Latitude Longitude Location 2 Latitude Longitude Location 3 Latitude Longitude Location 4 Latitude Longitude Location 5 Latitude Longitude Location 6 Latitude Longitude Location 7 Latitude Longitude Location 8 Latitude Longitude Location 9 Latitude Longitude Location 10 Latitude Longitude Location 11 Latitude Longitude Location 12 Latitude Longitude Page 1 of 1