R6 Br Overload Permit Form

U.S. DEPARTMENT OF AGRICULTURE – FOREST SERVICE

BRIDGE USE APPLICATION AND PERMIT

36CFR 261.12, and 261.54(c)

DATE RECEIVED:__________________ EFFECTIVE DATES OF PERMIT (Section for Forest Servcie Use Only) PERMIT NO.: _____________________ BEGINNING: ______________ TERMINATING: ______________ EXCLUDING: _____________

PERMITTEE/APPLICANT: ______________________________________ PHONE: _______________ ADDRESS: ____________________________________________________ FAX: _______________

REASON FOR PERMIT: TIMBER SALE:________________________________________________

CONSTRUCTION CONTRACT: __________________________________

OTHER: _____________________________________________________

DESIRED TRAVEL DATES: BEGIN: ____________ END: _____________

DESIRED TRAVEL ROUTE (Road #’s, Termini & Bridges): ___________________________________ TYPE OF VEHICLE: __________________________________________________________________

TOTAL GROSS WEIGHT:______________ POUNDS LICENSE NO: ____________ STATE: ____

MAXIMUM DIMENSIONS: LENGTH: ______________WIDTH: ____________ HEIGHT: ___________

VEHICLE DESCRIPTION

AXLE WIDTH TIRE WIDTH (OUT-OUT) NO. OF

AXLE AXLE SPACING AXLE LOAD (OUT – OUT) PER WHEEL LINE TIRES TIRE

NO. FEET & INCHES POUNDS FEET INCHES INCHES PER AXLE SIZE

1 P1 ___________ _____ ′ _____ ″ _______″ _____ _______ D1 _____ ′ _____ ″ 2 P2 ___________ _____ ′ _____ ″ _______″ _____ _______ D2 _____ ′ _____ ″ 3 P3 ___________ _____ ′ _____ ″ _______″ _____ _______ D3 _____ ′ _____ ″ 4 P4 ___________ _____ ′ _____ ″ _______″ _____ _______ D4 _____ ′ _____ ″ 5 P5 ___________ _____ ′ _____ ″ _______″ _____ _______ D5 _____ ′ _____ ″ 6 P6 ___________ _____ ′ _____ ″ _______″ _____ _______ D6 _____ ′ _____ ″ 7 P7 ___________ _____ ′ _____ ″ _______″ _____ _______ D7 _____ ′ _____ ″ 8 P8 ___________ _____ ′ _____ ″ _______″ _____ _______ D8 _____ ′ _____ ″ 9 P9 ___________ _____ ′ _____ ″ _______″ _____ _______ D9 _____ ′ _____ ″ 10 P10___________ _____ ′ _____ ″ _______″ _____ _______

SIGNATURE OF APPLICANT: NAME OF REGISTERED PROFESSIONAL ENGINEER EVALUATING BRIDGE(S)

FOR ABOVE VEHICLE: _______________________________________________(PE)

SIGNATURE: _______________________________

FOREST BRIDGE INSPECTION PROGRAM MANAGER RECOMMENDATION

__________________________________________ AND REGIONAL BRIDGE ENGINEER CONCURRENCE (Print Name) SUBJECT TO PROVISIONS AND ATTACHMENTS INCLUDED HEREIN

TITLE: _____________________________________ SIGNATURE: ___________________________________ DATE: _________ Forest Bridge Inspection Program Manager

DATE: ________________________ SIGNATURE: ___________________________________ DATE: _________ R-6 Regional Bridge Engineer

APPROVAL OF PERMIT

PERMISSION IS HEREBY GIVEN TO THE ABOVE APPLICANT FOR THE USE OF THE DESIGNATED BRIDGE(S) IN THE MANNER DESCRIBED, SUBJECT TO THE PROVISIONS AND ATTACHMENTS INCLUDED WITH THIS PERMIT

SIGNATURE: ____________________________________________ DATE: _____________ __________

TITLE: ________________________________________________________________________________ Forest Supervisor

36CFR 261.12, and 261.54(c)