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Driveway Encroachment Permit PROPERTY INFORMATION Property Address: Parcel ID: City: State: Zip: Is this driveway to serve as the primary driveway for the property? Yes No List the number of additional driveways on the parcel: OWNER & APPLICANT INFORMATION Owner Name: Mailing address: City: State: Zip: Phone: Email: Applicant Name (if different than Owner): Mailing address: City: State: Zip: Phone: Email: DRIVEWAY INFORMATION Side of Street: N S E W Nearest street: Distance to nearest street: Driveway Material: Asphalt Concrete Gravel Mailbox Support Material: Pipe Material: Concrete Corrugated HDPE OFFICIAL USE ONLY PERMIT CONDITIONS DO NOT WRITE IN THIS AREA 1. Does driveway require a Land Disturbance Permit? Y N 2. Does driveway meet site distance criteria: Y N (County Engineer can adjust the requested location of the driveway in order to maximize site distance) 3. Minimum Required Pipe Size: 4. Pipe to be extended as necessary to obtain 4:1 or flatter side slopes. 5. Existing surface flow to remain. No water shall be diverted into the County right of way (ROW). 6. No headwalls or other impediments shall be constructed without approval of County Engineer. 7. Mailbox support material must be approved by the County Engineer. 8. All disturbed ROW shall be stabilized to County specifications. 9. Driveway must be stabilized with a minimum of 4” of stone within ROW. 10. Permit must be onsite during Construction. 11. Notify the Engineering Services Division 24 hours prior to beginning work. ([PHONE REDACTED] or [EMAIL REDACTED]) 12. Special Conditions: Mailing Address: P O Box 498, Evans, GA 30809 Physical Address: 630 Ronald Reagan Dr, Bldg A 2nd Floor, Evans, GA 30809 Phone: [PHONE REDACTED] [EMAIL REDACTED] ---PAGE BREAK--- By signing below, I, the owner and/or applicant, agree to construct or have constructed a driveway as described above. I, the owner, agree that I will be responsible for the maintenance of this driveway including pipe, surface course, slopes and vegetation. The undersigned agrees to indemnify and hold harmless Columbia County (the County), its agencies and instrumentalities, and all of their respective officers, members, employees and directors from and against any and all claims, demands, liabilities, losses, cost or expensed, including attorney’s fees, and from the payment of any sum or sums of money to any persons whomsoever (including third persons or subcontractors, employees or agents of the undersigned or of Columbia County), for any loss due to personal injury, bodily injury, death, or property damage arising out of, attributable to, or resulting from this permit or in any way attributable to the activities authorized by this permit; or due to any violation of this permit by the permit holder, or due to the application or violation of any pertinent Federal, State, or local law, rule or regulation in connection with this permit or authorized by this permit. The undersigned acknowledges the permits can be granted in situations where limited sight distance exists, and that the County makes no warranty, express or implied, concerning sight distance or other engineering considerations involved in granting this permit. The undersigned further acknowledges that the County has relied upon the representations made by the undersigned in applying for this permit, including the undersigned’s representations that all conditions of the permit shall be met and that the undersigned shall meet all County specifications, as well as all relevant Federal, State and local laws, rules or regulation in the activities authorized by this permit. This indemnification shall apply where the County may be partially responsible for the situation giving rise to the claim. Owner Signature Applicant Signature (if different than Owner) Date: Date: