Structure No:	or Other:	Bench Mark Elev.:
Project ID:	Station:	Offset:

Fill in one description below (if applicable):

1. Located in the corner of the bridge on <insert road name> over ; in the ¼ ¼,(or Govt Lot, Private Claim, Farm Lot____,) Sec. , T N. R , Town of ,

County.

2. Located in the corner of the bridge in the bound lane of <insert road name> over ; in the ¼ ¼,(or Govt Lot, Private Claim, Farm Lot____,) Sec. , T N, R , Town of ,

County.

Vertical Datum
The Standard NAVD 88 (2012)
Alternatives NAVD 88 (2007) NAVD 88 (1991) NGVD 29 Other – Specify (NAVD 88 is not an option.)

Level LOOP (Known to Known) – Single stub\one way closure not acceptable. Attach level loop information if more space is needed. 2 setups required if using a direct read rod. Backsite/forsite/backsite reset and backsite/forsite/backsite minimum.

Point	B.S.	H.I.	F.S.	Elevation	Remarks

Surveyed By: (full name)
Checked By:
Company/Firm:
Date of Survey:
Project Manager:
Structure Number: (if applicable)
Accepted by: (Regional Survey Dept.)

Comments and/or Location sketch of Bench Mark.