Application to Construct Access Commercial Approach Roads, Streets, or Public Roads Private Driveway
Applicant: (Name and Address)	Date:
Phone:
Fax No.:
Email:
Location: Construct an access from the shoulder line or edge of pavement on the East West North South
side of Highway	and	feet East West North South of Milepost No.	.
If rural, the location is	feet East West North South of the East West North South
Line of Section	, Township	, Range	East West of the 6th P.M.,
County, Nebraska or if urban,	feet East West North South of the East West
North South Line of Lot	, Block	,	Addition, in
,	County, Nebraska, S	, T	R	East West .
(City)
Applicant requests a drive with a width of	feet at the property line.

Requirements: The applicant agrees to complete this work in accordance with the terms and conditions of the Nebraska Department of Transportation. Any permit issued will be cancelled if the work specified is not completed within the term listed on the permit or within any additional length of time granted. Request for an extension of time to complete the work must be made in writing. Any extension granted will be acknowledged in writing by the Nebraska Department of Transportation. The Applicant may cancel the permit with written notification at any time prior to beginning work on highway right of way.

Performance Guarantee: (Make payable to Nebraska Department of Transportation)
Amount: $	Check No.
Name and Address:
This guarantee is for the faithful compliance by the Applicant to the terms of the permit. It is understood that should the Applicant fail to perform the work as set forth in the permit, the State will have the right to keep the performance guarantee as liquidated damages for its necessary supervisory and inspection expenses and to initiate such legal proceedings as are necessary to secure either performance of the work in compliance with the terms of the permit or the restoration of the highway right of way to its previous condition prior to the activities of the Applicant.

NOTE: Please complete the attached location plan for access. When your access requires engineering plans, please submit two sets of plans, no larger than 12”x18” for the proposed work requested herein. The engineering plans shall show the general features of the work to be completed and all information such as sizes, distances, dimensions, cuts and fills, erosion control measures, etc., when applicable.
Name (Please Print)	Applicant’s Signature
Recommended By	Date	District Engineer Approval	Date

District Recommendations:

District approved if rural location is	feet East West North South of the East West
North South Line of Section	, Township	, Range	East West of the 6th P.M.,
County, Nebraska. If urban,	feet East West North
South of the East West North South Line of Lot	, Block	,
Addition, in	County, Nebraska, S	, T	, R	East West .

Location is in Controlled Access Area: Yes No

Other:

NDOT Form 22, April 2020

Location Plan for Access

Note:	All applicants must use this plan and fill in the required information.

Section	Township	Range	County
Indicate North Direction

Milepost	Milepost
Distance to closest milepost
Ft.	Ft.
No.	No.
Hwy. No.
Center of Approach
Centerline
R =	Ft.	R =	Ft.
Section Line	Section Line
Width
Ft.
Note: If culvert is required, the following information must be included.
In.	= Diameter of culvert
Culvert
Culvert
Ft.	= Length of culvert
Yes No	= Flared end section (if required)
Ft.	Ft.
Distance to closest section line

Note:	The following information is required on all plans:

Highway number

Distance in feet to nearest section line

Distance in feet to nearest milepost

Total width of new approach

Radius dimensions

Designate North direction

Complete legal description, including section, township, range, and county