Concrete Box Culvert Request Sheet

Date of Request:	Project Name:
Designer:	Project No.:
Phone Ext.:	Control No.:
TURN-IN DATE:	Highway No.:
LETTING DATE:	County Name:

See Orientation Sketch and Typical Section on the following page for notes, geometry definitions, and design parameters.

Structure No. or Reference Post No.	Station	No. of Barrels	Type of Work (New or Extend)	Side	Inlet or Outlet	Span (Ft.)	Rise (Ft.)	*Max. Fill (Ft.)	3 PARAPET Skew Angle (Degrees)	Slope for Wing Design Perp. to CL Roadway (Std. 3:1)	Length of Barrel (Ft.)	1 Wings Flared or Parallel	2 Paved Apron Required (Yes or No)
1.	R
L
2.	R
L
3.	R
L
4.	R
L
5.	R
L

* Note:	For all fills >20’, contact NDOR Geotechnical Section for camber recommendations.

Remarks:

NDOT Form 67, July 17

4 Additional Information for Extensions
As-Built Project No.	Standard/ Special Plan No.	Existing Fill (Ft.)
1.
2.
3.
4.
5.
NOTES: 1. Standard wingwall design is based on a 3:1 sideslope around the wings, unless specified otherwise. Please specify Flared or Parallel. 2. If Paved Apron is requested, please provide elevations for A and B (see sketch). 3. When providing skew angle, it is the skew at the parapet, not at the roadway (see sketch). 4. Additional information is needed when the extension is on a weird shaped or odd sized existing culvert, or if raising parapet(s).