- Preliminary		    	 - Congressional District	
 - Final 25C            LOCAL GOVERMENT BRIDGE REPLACEMENT/REHABILITATION
                                           
A.  FEDERAL AID PROGRAMING DOCUMENT                                                                ADT 
Federal Contract No	     		Local/Termini:	     		Present/Yr.:	     	
State Contract No	     		     		Future/Yr. :	     	
Local Contract No.	     		     	Project Length:	     		Federal-aid System:	     	
Item No.	     		State Road Inventory Milepoints:	     		Probable Ad Date:	     	
						
Local/State Supplemental Agreement Required:	Yes		No	  	SHADED AREA TO BE FILLED OUT BY SHA	
B.  WORK PHASE             Total Cost  Federal Funds  State/Local	      E.  ENVIRONMENTAL    
PE	     	     	     		Catagorical Exclusion No.	(Date:     )	
ROW	     	     	     		Envir. Assessment/FONSI	(Date:     )	
Constr.(Neat & 10%)	     	     	     		Envir. Impact Statement	(Date:     )	
Project Total:	     	     	     		4(F) Statement	(Date:     )	
C.  PUBLIC HEARINGS								 		
	Required		Location Hearing	(Date:      )	F. PLANNING					
	Not Required		Design Hearing	(Date:      )	   Clearing House Control No.	     		Exempt	
	To be determined		Combined Hearing	(Date:      )	   Urban Area			Exempt	
						   TIP No.	     	STIP No.	     	
D.  PREVIOUS FEDERAL-AID PROJECTS	PE	     	ROW	     					
G.  PROJECT DESCRIPTION
1. Existing Conditions:      	
2. Proposed Project:      	
3.  Additional right-of-way     required?		Proposed width:	     	Relocation(s) required?		No. of businesses/residents:	
     	
H.  BRIDGE ELEMENTS 												     
	Bridge Replacement	Bridge No.	     		Code:	     	404 Permit (Navigation 		Required	
	Bridge Rehabilitation	Sufficiency Rating	     		Bridge Length:	     	 Clearance)		Not Required	
I.  CONSTRUCTION DATA   
1.  Construction within 2 miles of airport?						
2.  Contract Award: 		Bid 		Force Account		Other, explain	     	
    If force account, work by:	     	
3.  Utility relocation/adjustment required?		Name of Utility	     	Estimated Cost	     	
    Railroad relocation/adjustment required?		Name of Railroad	     	Estimated Cost	     	

PREPARED BY:	     	DATE:	     	TELEPHONE:	     	COUNTY/FIRM:	     	
SHA Recommendation for Approval:                  SHA Approval of Federal Funds:             SHA/FHWA Approval of Federal Funds:                     

_                                           	                             	        ____	                                       	 
Director, Bridge Development            Date      Dep. Admin./Chief Engineer      Date                                          Date 

SHA Contract No.	     	SHEET 2 of 2	
F.A.P. No.	     		
                          
												   Rural Road

I.  DESIGN DATA:  									          Urban Road

DESIGN ELEMENT	* EXISTING
ELEMENT	* PROPOSED
DESIGN CRITERIA	** MEETS SHA/ASSHTO DESIGN STANDARD	
Design Speed	     	mph.	     	mph.		
Posted Speed Limits 	     	mph.	     	mph. 		
Number of Lanes  	     		     			
Through-Lane Width	     	ft.	     	ft.		
Aux.-Lane Width  	     	ft.	     	ft.		
Shoulder Width    Right	     	ft.	     	ft.		
                   Left	     	ft.	     	ft.		
Cross Slope	     	ft./ft.	     	ft./ft.		
Horizontal Alignment:						
   Curvature *						
   Superelevation *						
   Sight Distance *						
Vertical Alignment:						
   Grades *						
   Sight Distance *						
Bridge Clear Width	     	ft.	     	ft.		
Bridge Railings *						
Median Width	     	ft.	     	ft.		
Clear Zone Width	     	ft.	     	ft.		
Ditch Slopes (front/back)	     		     			
Culvert End Treatments *						
Guardrail *						
Signing *						
Pavement Markings *						

* Indicate yes, no, or N/A whether "Existing Condition" meets applicable SHA Design Guide standard. 
   Indicate yes, no, or N/A whether "Proposed Design" will improve existing condition.
                                                                                          
** If criteria does not meet applicable standards, a design exception must be requested
   prior to P.S.&E. submittal.
                               
J.  CERTIFICATION              

    - This project meets all applicable AASHTO/SHA design criteria.
         Approval of the SHA Chief Engineer is not required.

    - The construction of this project incorporating the above design feature is recommended for
	  Federal funding.  Justification for proposed design elements that do not meet applicable 
	  AASHTO/SHA design criteria, and three-year accident history/analysis are attached.

         Note:  Complete Sections 1 (Design Data) and J (Certification) using the information available. 
	         Missing or revised data should be provided as the project develops.