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Orange County Agricultural Preservation Board APPLICATION FOR CERTIFICATION AS QUALIFYING FARMLAND AND DESIGNATION AS AN ORANGE COUNTY VOLUNTARY AGRICULTURAL DISTRICT INSTRUCTIONS: Before completing the application, please review the provisions of the Orange County Voluntary Farmland Preservation Program Ordinance, then fill out the form as accurately and completely as possible. Please sign and date the form, and return it to the Orange County Environment and Resource Conservation Department, 306A Revere Road, Hillsborough, NC 27278 APPLICANT: ~ ( rte, Name: IVll'Otl~~ ~ p~C~ I S h- Ln~E~7VI ~GrG Yl'tCv47 rl Address: '-Y ~ ~iZ' s~ J c.~ ~rVl t~C City: ~1 GM-/~ ~1 State: 1`1 ~- Zip Code: ~ ~ ~-~ Phone Number (Day): °~ I ~ LfS~~- (Evening) S a/~'i~-a-. E-Mail: ~i~ Ca'"G'C ~ ~ Yr~e(~~~ • t~ PROPERTY INFORMATION: Property Location/Address: 5C~tit'- - Township:4'~+_t~_>/ -I'axMnap: 3~" .12A Block: Lot: Pazcel Identification Number (PIN): / ~ ~2- ~ ~y~ ~ N ~ ~ ~ 6 ' 1 Number of Acres: G Q ~~5 Deed Book: J 3 Page: ~ ~1' q~2. 33 Does this land have a plan on file with the Natural Resources Conservation Service or NC Forest Service? Yes: No: It `No", please complete back of form Is this land lis g for Present Use taxation with [he Orange County Tax Office? Yes:~No: If "No", please complete back of form OWNER[S7 CERTIFICATION: I [We], the applicant(s), hereby certify that, to the best of my [our] knowledge, the foregoing application..is~7c~omplete and acc/t~uate. Signature: bevtti~L ~'/C.3 Date: ~ /'~D t/ d5' Please direct inquiries to: c% Orange Cortnty Envvm:ment and Resource Conservation Deparhnenf 30GA Revere Road Hillsborough, NC 27278 Ilillsborough • 732-8181 Chapel Hill • 967-93SI Durham • 688-7331 Mebane • 2?7-?031