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bdkmL Orange County Agricultural DISrI"1Cts Addison, 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 till 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, 306F Revere Road, Hillsborough, NC 27278 APPLICANT: 064141al 12/. - * -�i��'d� 17 � Name: M4. r' V G _ EA-CO A) S,4Co,� 0.nm ly � `^n T P Q�`�)tie %S�t. P Address: /Z 3 S % � ma T y,�y Rd City: 11^4u6� /j State: /UC Zip Code: J 7,� 7 Phone Number (Day): ` JU 2-2 ,� _ r.j vV(Evening)_ 7 J:2 - 3 2 Z rnr-5,&C,0 E -Mail .ti (° /ryl n�5'Pr,tlj'• C b PROPERTY INFORMATION: P ation/Address:_ 39e) 1 5 T_ mom. t-Y s f?d 10-310 JT Pwnship: —Tax Map: Block: Lot:_ / / 4-4041 '? Rine S Parcel Identification Number (PIN): I-LA C.-5$ 289,5'0 mor— i / Number of Acres: 72 /*�CX Deed Book: Q. o.2,::5 Page: .5S Does this land have a plan on file with the Natural Resources Conservation Service or NC Forest Service? Yes: No: ! If "No ", please complete back of form Is this land listed for Present Use taxation with the Orange County Tax Office? Yes:—.---' No: If "No ", please complete back of form OWNER[S] CERTIFICATION: I [We], the applicant[s], hereby certify that, to the best of my [our] knowledge, the foregoing application is complete and accurate. Signature: l`72 Date: //1 7- z e&/ Signature: A&_141 h &Lzro Date: % % Please direct inquiries to: c% Orange County Environment and Resource Conservation Department 306F Revere Road Hillsborough, NC 27278 Hillsborough • 732 -8181 Chapel Hill • 967 -9251 Durham • 688 -7331 Mebane • 227 -2031