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4 <br /> Orange County Agricultural Preservation Board <br /> APPLICATION FOR CERTIFICATION AS QUALIFYING FARMLAND <br /> AND DESIGNATION AS AN ORANGE COUNTY <br /> VOLUNTARY AGRICULTURAL DISTRICT <br /> INSTRUCTIONS: Before completing the application,please review the provisions of the Orange <br /> County Voluntary Farmland Preservation Program Ordinance,then fill out the <br /> form as accurately and completely as possible. Please sign and date the form,and <br /> return it to the Orange County Environment and Resource Conservation <br /> Department,306A Revere Road,Hillsborough,NC 27278 <br /> APPLICANT: <br /> Name: �� // d / � •^ �H`` <br /> Address:_ <br /> City. state: &�. P_ zip Code: <br /> Phone Number(Day): q!9-✓``� "3?2 U (Evening) 4 mE <br /> . E-Mail:CWdn,�7s'e� 0K{Awrt �/fsn�l <br /> PROPERTY INFORMATION: <br /> Property Location/Address: s rt' <br /> Z Z g .. i N 7, 2 Fria <br /> Township: 2 Tax Map: a 9- Block: Lot: • �/� /v. om s <br /> O 9838- 47-7077 <br /> Parcel Identification Number(PIN): D W 3 t- 5 7 -So S eo <br /> Number of Acres:_ _Deed Book: Page: <br /> Does this land have Ian on file with the Natural Resources Conservation Service or NC Forest <br /> Service? <br /> Yes: No: If'No",please complete back of form <br /> Is this land ' for Present Use taxation with the Orange County Tax Office? <br /> Yes: If"No",please complete back of form <br /> OWNER[S]CERTIFICATION: <br /> I[We],the applicant[s],hereby certify that,to the best of my[our]knowledge,the foregoing <br /> application is co plete and accurate. <br /> Signature. �• Date: <br /> Signatur Date: ,l9 <br /> Please direct inquiries to: <br /> c%Orange County Environment and Resource Conservation Department <br /> 306A Revere Road <br /> Hillsborough,NC 2 72 78 <br /> Hillsborough•732-8181 Chapel Hill•967 9251 Durham•688-7331 Mebane.227-2031 <br />