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5. <br />Orange County <br />Agricultural Districts Advisory Board <br />APPLICATION FOR CERTIFICATION AS QUALIFYING FARMLAND <br />AND DESIGNATION AS AN ORANGE COUNTY <br />VOLUNTARY AGRICULTURAL DISTRICT <br />INmucnONS: Before completing the application, Pleam review the pmvissons of the Orange County voluntary Farmland <br />Preservation Prngraln OniinAnce, then fill Out the form as aoea M* sad completely as Possible. Be sure to <br />sign and date the form, and return it to the Change Carroty Planning & Inspections Department, 306F Revere <br />Road; Hillsborough, N.C. <br />M-1 -9*140zilf. <br />Name: <br />Address: <br />City: State: ZIP Code: a zZ <br />Phone Number: (Home) (Work) <br />PROPERTY INFORMATION: . <br />Prop24� =fion�=ss: jJ <br />Township: C If S:: 5 Tax Map: S / Block. Lot: / <br />Parcel Identification Number [PIN]: 8 <br />Number of Acres: Deed Book: .5 ;Z Y- Page: 154 9 <br />Does this land have a plan on file with the Soil Conservation Service or U.S. Forest Service? <br />Yes: X No: If "no ", please complete back of form. <br />Is this land listed for farm present use -value taxation with the Orange Countv Tax Office? <br />Yes: No: 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] ability, the foregoing <br />application is complete and accurate. <br />Signatur�e:.,� Date- <br />Signature: 6 <br />4 <br />Date: <br />Please direct inquiries to: <br />Orange Soil & Water Conservation District <br />Cooperative Extension Service <br />Orange County Planning & Inspections Departtnert <br />HAsbo,uugh 732 181@Cba* tm967401•Dur6m 6er-7031al -It .227 -2091 <br />