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3 <br />Orange County Agricultural Districts Advisory 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: / ~ tC ''"~S ~-~~"~ <br />Address: ~f ~ O ~~/Q ~ ~ ~~~ ~~ ~ ~ ~ , <br />City: ~~~~''~~ State: ~ L Zip Code: c~ l o~~ 3 <br />Phone Number (Day): ~~ 9 ~ ~3 °~ - ! 7d i (Evening) 9/4 ' ~ 3 °~ '~y5'S Z <br />E-Mail: 1'4\C~r{sf~Y'r~~@Y~ 5i ~e~ . dC~ <br />PROPERTY INFORMATION: <br />Property Location/Address: llac~ ~J ~a~~ L~'~' ~r~"~ 1`'~[ , ~~? ~~~ <br />Township: C~'~'S Tax Map: Block: Lot:_ <br />Parcel Identification Number (PIN): <br />Number of Acres: Deed Book: 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. p/ ~j <br />Signature: ~~ ~r Date: ~-l~ ~ ® 7J <br />Signature: Date: <br />Please direct inquiries to: <br />do Orange County Environment and Resource Conservation Department <br />306F Revere Road <br />Hillsborough, NC 27278 <br />Hillsborough ~ 732-8/87 Chapel Hill ~ 967-9151 Durham ~ 688-7331 Mebane ~ 227-2031 <br />