Name/Company/Agency name Street Address City, State Zip Code Phone Number Email AddressCurrent Date File: District-County-Route Postmile(s) XX/YY EA/PI No. or Permit No.
Name (All Caps) Title Encroachment Permits Office District X Traffic Operations
Subject: encroachment or Utility policy exception
Request Statement
In a 1-2 sentence summary, identify the project owner and briefly describe the project scope and exceptions being requested.
Project Description
Describe the proposed project, including, but not limited to, project location, route information, purpose and need for the project, scope of work, schedule, and cost.
Encroachment and/or Utility Policies Addressed in this Exception Request
List the proposed features and cite the applicable encroachment and/or utility policy from the Project Development Procedures Manual (PDPM), Chapter 17, Encroachments and Utilities, that will require an exception.
Ingress, Egress, and Potential Impacts to Highway Operations
Briefly describe the method to access the proposed installation within Caltrans’ right-of-way during construction, including a description of traffic control and/or any proposed access through existing fences or gates, and after construction, including the frequency of monitoring, maintenance, and inspection activities for the proposed feature(s) of the installation. Also discuss any potential impacts to the current or future operation of the highway due to proposed construction, maintenance, or inspection activities.
Access Control Modifications
Briefly describe if there will be any temporary and/or permanent modifications to the highway access control or locked gate access requests, including, but not limited to, removal or replacement of existing fences, installations of new gates, temporary construction access openings, and non-motorized openings. Access control modifications within Interstate highway right-of-way require Federal Highway Administration (FHWA) review and approval.
Preferred Design Option Requiring the Exception
Discuss, in detail, the preferred design and location for the proposed feature that requires an approved encroachment and/or utility policy exception. The discussion should include information regarding design decisions, mitigation features, and applicable district consultations.
Provide compelling justifications for why the project requires an exception to an encroachment and/or utility policy. Discuss how the encroachment will not adversely affect the safety, design, construction, operation, maintenance, or stability of the highway and will not interfere with or impair the present use or future expansion of the highway.
If the project will not comply with the utility policies described in PDPM Chapter 17, Section 3, list the policy in the section of this form titled “Encroachment and/or Utility Policies Addressed in this Exception Request” and provide justifications for requesting a utility policy exception.
List and describe any approved agreements, such as maintenance agreements, joint use agreements, or consent to common use agreements, and provide a copy as an attachment. If the project will modify an existing encroachment, briefly list and describe the previously approved encroachment permit(s) and/or lease agreements within the Caltrans’ right-of-way.
Discuss other exception documentation that was needed and approved for the project, such as a Design Standard Decision Document (DSDD) or an exception to trenchless installation.
Other Design Options Considered to Meet Policy
Identify alternate locations and/or design options that were evaluated and discuss why these options are not viable or cannot be implemented, at a reasonable cost, in a manner that is beneficial to the safety, durability, and economy of the state highway operations and maintenance. Include the estimated project costs and impacts for each design option considered, such as constructing the feature outside of Caltrans’ right-of-way or considering different locations or alignments.
Existing Utilities and Utility Conflict Resolution
List each utility owner and their respective facilities that are located within the work area of the proposed encroachment. Describe the design options or mitigations that were added to the project to resolve conflicts with any of these existing utilities.
Cost and Benefit to the State Highway System
Include a discussion of the potential costs and/or benefits to the State and to the project if the request for a policy exception is granted. Discuss potential impacts to highway maintenance and operation costs or to costs associated with a current State highway project. Describe any benefits that will provide a betterment to the future safety, maintenance, operation, or design of the State Highway System.
Environmental Determination/Documentation
Provide the approval date(s) of the environmental determination for the project, which is needed before an encroachment exception request can be considered. For projects within Interstate highway right-of-way, a National Environmental Protection Act (NEPA) determination is required as an attachment.
Structure Involvement and Concurrence
Provide relevant information about proposed impacts to existing structures, installations proposed near existing structure foundations, or when a new structure is proposed. Structures Maintenance & Investigation or the Division of Engineering Services is required to review the proposed design option and provide a concurrence signature and date.
Structural Concurrence by:
Name Date Title
Attachments
List attachments here. At minimum, exception requests should include items 1-3. Use a printable paper size of 8.5 X 11 or 11 x 17.
1. Project location map and/or project vicinity map. 2. Proposed typical cross sections, layouts, profiles, and construction details related to the encroachment, as applicable. 3. Plans and supporting documentation for other alternatives considered. 4. NEPA determination, if applicable. For encroachment permit submittals, contact the District Encroachment Permits Office for more information. 5. Copies of project agreements, if applicable. 6. Other attachments related to the exception, as applicable.