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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:—/ s r� r' 17� h � 1/ � 1 �J r <br />Address: e�l <br />j <br />City: �j � f� State:l Zip Code: '7 3 <br />Phone Number (Day):( J & 3 (Evening) <br />E -Mail: <br />PROPERTY INFORMATION: }} <br />Property L,ocztionlAl <br />dress: 6 r C �-� P 14 ; rl � 6 <br />p� L, <br />Township: Tax Map: Block: Lot: -� <br />Parcel Identification Number (PIN) <br />?e-� ? - C�y - /3 / Y/ <br />Number of Acres: ) �, Deed Book:'M 3 6 1 Page: --), <br />Does this land have a plan 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 listed for Present Use taxation with the Orange County 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] knowledge, the foregoing <br />application is complete and accurate. <br />Signature: L1, Ltjll MI f Date: <br />, r <br />Signature: !�' r- It) a - Date: 5 °� — d <br />Please direct inquiries to: <br />c% Orange County Environment and Resource Conservation Department <br />306A Revere Road <br />Hillsborough, NC 27278 <br />Hillsborough • 732 -8181 Chapel Hill # 967 -9251 Durham • 688 -7331 Mebane • 227 -2031 <br />