Form  MT-39A    11/2014	NEW JERSEY DEPARTMENT OF TRANSPORTATION	APPLICATION
NUMBER      	
	APPLICATION FOR DRAINAGE	COUNTY      	
SUBMIT IN DUPLICATE		
The required fee must accompany this application,
either by money order or check, payable to the New
Jersey Department of Transportation.

- CASH WILL NOT BE ACCEPTED -		MUNICIPALITY      	
  Please Print or Type				ROUTE NO.      	
				M.P.      	
				AMT. RECEIVED      	
				CHECK NO.      	
APPLICATION			DATE
RECEIVED      	
MADE BY	     			
	                                                     (Property Owner)	(DEPT. USE ONLY)	
MAILING	     	     	     	     			
ADDRESS							
                        (Street)                                               (City)                                     (State)               (Zip Code)		
TELEPHONE NUMBER	     		
			
for permission to construct drainage facilities on the	     	  side of Route No.	     	side	
			
Approximately	     	feet	     	of	     	
	(Direction)		(Intersecting Street, Stream or Other Landmark)	
				
in	     	in the County of	     	  for the purpose of	     	
(Municipality)				
		
     	
(Describe Fully)	
	
     	
     	
	
* NOTE:  Submit two (2) copies of this application and six (6) copies of a detailed plan drawn to scale showing the proposed 
                installation and whatever data is necessary for a complete understanding of the request. A Traffic safety setup as 
	 per the “Manual on Uniform Traffic Control” is required with application. The Department will not be responsible for	      	 any errors or misinformation given in the application and/or on the accompanying plans.

The undersigned certifies that (he) (she) is the sole owner of the property for which this application is made and affirms that the following stipulations will be observed:

1. 	The connection will not involve diversion or drainage that is unnaturally tributary to the highway system.	
		
2.	Where appurtenant drainage rights or easements have been acquired by the State, no construction shall take place which will adversely affect these rights.	
		
3.	The installation will not be used for the discharge of sanitary, industrial waste or other toxic effluents into State’s storm system.	
		
4.	Violation of any of the covenants and conditions contained herein and on the reverse side of this form will be cause for summary revocation of permit and severance of the connection. Not withstanding complete compliance with the terms of this agreement, and if the interest of the State so requires, the right is reserved to revoke this permit including all privileges and permission granted hereunder upon 30 days notification.	

FEE SCHEDULE	
Application	Permit	
(Only Submit Required Application Fee)	(Do Not Submit permit Fee With Application)	
		
	Drainage Facilities	Application		Permit		Extension	
			
	1 to 5				Unit	   $230.00		$65.00		  $65.00	
	Greater than 5			Unit	   $525.00		$200.00		  $200.00	
	0 to 200				SF	   $230.00		$65.00		  $65.00	
	Greater than 200			SF	   $525.00                           $200.00                  $200.00	

APPLICATION FEES ARE NON-REFUNDABLE

If a permit is granted, I or we, agree to comply with the rules and regulations of the New Jersey Department of Transportation as set forth in the conditions included therein and on the reverse side of this form. In addition, I or we understand that N.J.S.A. 27:7-44.1 makes any violation of the provisions of the permit subject to a fine (Note exceeding $100 per day) and civil action for the costs of prosecution as well as civil action for trespass to remove any non-conforming use. No work in connection with this application will be started until the final permit is approved and issued.

Enclosed is the required fee, in the amount of $	     	

     						   		     				     	
(Signature of Owner or Authorized Representative)			(Title)				(TYPE OR PRINT)	
	
     										     	
(Print or Type Your Name)								(Date)	

CONDITIONS

PROTECTION FROM SUITS
The permittee shall defend, indemnify, protect and save harmless the State and its agents, servants, and employees from and against any and all suits, claims losses, demands, or damages of whatever kind or nature arising out of or claimed to arise out of, any negligent act, error, or omission of the permittee, its agents, servants, and employees in the performance of the work covered by this permit.

PROTECTION OF THE TRAVELING PUBLIC
The permittee shall properly safeguard all work performed under this permit, and during hours of darkness maintain sufficient warning lights or employ other measures necessary for the public’s protection.

PROTECTION OF STRUCTURES
There shall be no interference with any structures on, over or under the highway. The existing cross section and drainage of the highway shall not be disturbed. The longitudinal flow of water along the gutter line must not be interrupted. It shall be the responsibility of the owner to make adequate provision for all transverse, lateral and longitudinal drainage affected by his construction.

SETTLEMENT OR DISLOCATION
The permittee shall take all necessary precautions to prevent settlement or dislocations of, or damage to existing adjacent
roadways or other facilities. If such roadways or facilities be damaged by or as a result of the work, they shall be repaired, replaced or otherwise restored to a condition as good as prevailed at the time the project started, by and at the expense of the
permittee.

MANHOLES, INLETS, AND CATCH BASINS
Concrete for the foundations of brick, concrete block or concrete manholes, inlets and catch basins, shall be Class D. For the 
walls of concrete inlets, manholes and catch basins, the concrete shall be Class C. Top slabs, if required, shall be of Class B Concrete.

INSTALLATION OF PIPES
Pipe must not protrude beyond the inside walls of the Highway drainage structure and space between wall and pipe is to be
chinked with 1:2 Portland Cement Mortar. The Department, under no circumstances, will bear any part of the expense of the installation of pipe which may be necessary, nor will it furnish or place fill material either within right-of-way of the highway or outside of it. The permittee may be required to construct manholes, catch basins or both where drainage conditions or future maintenance conditions may be such that these structures are necessary.

EXCAVATION AND RESTORATION
All excavations shall be completely backfilled and the excavated material shall be replaced. Compaction shall be accomplished by mechanical tamping or as otherwise directed. Additional material shall be supplied when a deficiency occurs. If the Inspector considers the excavated material unsatisfactory for backfill, approved material shall be supplied and the excess unapproved material removed from the site. All backfill material shall be placed in lifts not exceeding 12 inches in depth, moistened, if directed, and lift shall be energetically tamped until thoroughly compacted. Upon completion of work the area disturbed shall be properly restored and all excess material, if any, shall be removed. In pavement areas, if immediate replacement or permanent pavement is not feasible, the excavation shall be backfilled and consolidated as specified above, after which not less than two (2) inches of cold patch material shall be placed to grade. Temporary pavement must be maintained in a condition satisfactory to Department of Transportation until permanent pavement restoration has been completed.

MATERIALS AND WORKMANSHIP
Materials and workmanship used in construction affecting Highway property shall be in accordance with the Department’s Standard Specifications and are subject to inspection and approval of the Department of Transportation. Where conditions warrant, the Department may assign an inspector to the project at the expense of the permittee. The Department shall reserve the right to demand from the applicant as a condition of any permit, a bond or certified check in an amount sufficient to guarantee or insure the proper maintenance and restoration of the area disturbed.

SPECIAL CONDITIONS
The Department of Transportation may impose special conditions in special cases.

DRAINAGE RIGHTS
Where appurtenant drainage rights or easements have been acquired by the State, no construction shall take place which will adversely affect these rights.

VIOLATIONS
Violation of any of the covenants and conditions contained herein and on the reverse side of this form will be cause for summary revocation of permit and severage of the connection. Not withstanding complete compliance with the terms of this agreement, and if the interest of the State so requires, the right is reserved to revoke this permit including all privileges and permission granted hereunder upon 30 days notification.