Form M-936a Rs Application - Route Survey
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1APPLICATION - ROUTE SURVEY
M-936ARS (3-09)
Click to Print
Application ID#:
THIS SURVEY IS VALID FOR 21 DAYS FROM
DATE SURVEY IS PHYSICALLY PERFORMED
_______________________________
The routes shown below for the movement of a _____________________________________________________________
(Load Description)
having a Gross Weight of ________________________________________________ pounds and Maximum Dimensions of
Length: ________ FT. _____ IN.
Width: ________ FT. _____ IN.
Height: ________ FT. _____ IN.
moving from:
ORIGIN
PA County
PA Town (optional)
State
ORIGIN:
State Route
Direction:
Point of Interest
Starting Point
Miles/Direction from Intersect
Intersection
DESTINATION
PA County
PA Town (optional)
State
State Route
Direction:
Point of Interest
Ending Point
Miles/Direction from Intersect
Intersection
have been physically surveyed on ________________________________________________ and it is hereby certified by:
(Date survey performed)
_________________________________________________ ________________________________________________
(Company Performing Survey)
(Person Performing Survey)
for: _______________________________________________________________________________________________
(Responsible Motor Carrier Name)
that (1) there is safe and sufficient clearance throughout the entire proposed routing as detailed below, (2) turns at all intersections can be
traversed, (3) all overhead structures can be traveled under, (4) steep grades can be traversed, (5) cities are identified, (6) all parking and
stop-off locations are identified, (7) the vehicle Gross Weight does not exceed any highway or bridge posted weight limit, (8) the survey has
been physically performed by actually driving the entire proposed routes, (9) State Routes are identified by SR number, (10) local roads
and streets and other non-PA state highways are listed in (parentheses) for routing continuity, and that authorization for their use will be ob-
tained by the applicant from the appropriate authority.
Detailed proposed routing: _____________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Attach additional 8 1/2 x 11 sheet(s) if necessary
Upon request, submit digital photos of each “turning” intersection and each structure that has less than three inches of vertical
clearance (measured from pavement) and identify proposed travel lanes at these locations.
Surveyor Signature(s): ____________________________________________________________ Date: _______________
Surveyor Phone Number: (______) __________________________ Fax Number: (______) _________________________
FALSE INFORMATION GIVEN ON THE PERMIT APPLICATION SHALL AUTOMATICALLY INVALIDATE THE PERMIT.
THIS DOCUMENT MUST BE COMPLETED BY SURVEYOR
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