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ROW Page 1 of 2 PERMIT#: DAWSON COUNTY ENCROACHMENT APPLICATION/PERMIT APPLICATION AND PERMIT FOR UTILITY FACILITY ENCROACHMENT AND/OR ANY OTHER ENCROACHMENT ONTO COUNTY RIGHTS-OF-WAY OR COUNTY ROADS. Applicant Name: Address: Contact Person: No.: Email: For permission to construct, operate and maintain the following described project within the limits of right- of-way for the County Maintained Road known as Location and description of utility or other type of encroachment to be installed: A detailed plan (drawing) of the project shall be shown on a separate sheet and attached to this application and shall be made a part of this application/permit. The issuance of a right-of-way encroachment permit does not constitute an easement. This right-of-way encroachment permit is for the use on the right-of-way only. Any and all damage caused upon the right-of- way because of installation or relocation of the utility or other encroachment shall be at the sole expense of the applicant or applicant’s assigns. If Dawson County or its assigns makes improvements or changes to the right-of-way, then the applicant or applicant’s assigns shall be required to relocate the utility or encroachment at the expense of applicant or applicant’s assigns. If relocation of the utility or encroachment requires installation outside of the right-of-way, then Dawson County or its assigns shall bear the cost of relocating the encroachment or utility. Dawson County or its assigns shall not be required to bear the expense to relocate any utility or other encroachment as long as right-of-way is provided for such utility or encroachment. All utilities crossing the County Right-Of-Way shall be placed three feet below top of roadbed, dry bored, and in casings (NO CUTTING INTO ROADWAY). Utilities running parallel with County Right- Of-Way or roadway shall be placed within the last five feet of County Right-Of-Way, and three feet deep. Cuts cannot exceed twelve (12) inches in width. Where County Right-Of-Way is ditch to ditch, applicant must obtain its own Right-Of-Way. All underground utilities shall be marked prior to beginning work. It is the responsibility of the applicant/utility owner to verify the limits of Right-Of-Way for the location of the facilities authorized hereby. The utility or encroachment covered hereby shall be installed in accordance with the attached plan and subject to all Dawson County regulations for the control and protection of County maintained roads and County Right-Of-Way. Applicant is responsible for temporary traffic control. Traffic control must be in accordance with Chapter 6 of the MUTCD. All disturbed areas of Right-Of-Way shall be returned to as good or better condition. All work must be guaranteed for 18 months. Any deficiency found upon inspection will be at the expense of said utility company to repair or replace. If the County undertakes to improve or relocate any portion of the County Maintained Road, the applicant/utility owner shall be solely responsible for the expense of removing or relocating the utility. ---PAGE BREAK--- ROW Page 2 of 2 Should the applicant fail to remove or relocate its facilities, upon due notice from the County, the applicant/utility owner shall be liable for any extraordinary costs or damages incurred by the county as a result thereof. Applicant/utility owner must contact Dawson County Public Works Department at [PHONE REDACTED] forty- eight hours prior to beginning work authorized by this permit. All work must commence within six months of the date of approval of permit. Work, other than maintenance, shall be completed within one year of the date of approval of permit and must be inspected by the Public Works Department and approved by the Public Works Director upon completion. Indemnification of Dawson County: The applicant, shall indemnify and hold harmless Dawson County from loss by reason of damage or injury to person or property caused by or resulting from cutting or removing trees upon the right-of-way or from any other cause associated with the issuance of this permit, exclusive of damage caused by or resulting from intentional misconduct of Dawson County’s representatives. Applicant shall defend, at Applicant’s sole cost and expense, any lawsuit or claim resulting from any activity related to this permit. Applicant shall keep in force during the term of this permit a liability insurance policy or a bond in the sum of Special Requirements – (Attached if applicable) Permit requested this the day of 2024. The signing of this permit application commits the applicant to the Stipulations in the permit. (Applicant/Utility Owner) Return Application to: Dawson County Public Works 25 Justice Way Suite 2232 Dawsonville, GA 30534 ATTN: Public Works Recommendation for approval: Public Works Director This permit is to be strictly followed and no work other than that specifically described is hereby authorized. Date Dawson County Manager To be reviewed and approved by Public Works Department after work has been completed: The installation described on this permit form has been completed in accordance with the provisions of this permit and the plan attached hereto. Date Public Works Director OFFICE USE ONLY Work Beginning: First Inspection: (Date) (Date, Initials) Final Inspection: Work Completed Properly: Yes No (Date, Initials) (Circle One)