COUNTY OF NEWBERRY ENCROACHMENT PERMIT APPLICATION

NAME  ____________________________________________________________

ADDRESS  _________________________________________________________

CITY  ______________________________________________________________

COUNTY__________________________ ______

PHONE  ___________________________

LOCATION OF ENCROACHMENT_____________________________________

____________________________________________________________________

TYPE OF WORK TO BE PERFORMED	_______________

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DATE ______________________________________________________

PERMIT NUMBER  ____________________________ ________________

PERMIT ISSUED BY_________________________________________________ NEWBERRY COUNTY

APPLICANTS NAME  ________________________________________________

SIGNATURE________________________________________________________